Summary:

The Clinical Documentation Registered Nurse collaborates extensively with physicians, nursing staff, other patient caregivers and coding staff to improve the quality and completeness of documentation of care provided and coded for coordination, abstraction and submission of accurate data required by CMS. Facilitates concurrent modifications to clinical documentation to insure commensurate reimbursement of clinical severity and services rendered to patients with a DRG based payer (Medicare, Medicaid). Supports timely, accurate and complete documentation of clinical information used for measuring and reporting physician and facility outcomes. Communicates with and educates all clinical staff concerning accurate and effective clinical documentation.

• Reviews inpatient medical records for identified payer populations as within one business day of admission and throughout hospitalization to identify opportunities for physician documentation.
• Analyzes clinical status of patient, current treatment plan, and past medical history and identifies potential gaps in MD documentation and leaves physician query to obtain complete, accurate clinical documentation.
• Works closely with HIM coding staff to assure documentation of discharge diagnosis and any co-existing co-morbidities is a complete reflection of the patient’s clinical status and care
• Maintain a DRG worksheet to assist coders on identifying all documented POA/HAC, diagnosis and procedures
• Updates DRG worksheet to reflect any changes to inpatient status/procedure/treatment and confers with the physician to finalize diagnosis.
• Demonstrates basic knowledge about HIM coding standards and applies to ongoing evaluation of medical record documentation for accuracy of physician documentation to support the acuity of illness.
• Performs chart review on expired patients to identify severity of illness and risk of mortality for performance improvement activities.
• Develops and implements plans for both formal and informal education of physician, nursing, and other clinical staff on clinical documentation opportunities, coding and reimbursement as well as performance improvement methodologies.
• Collaborate with case manager regarding cases with length of stay outside of the expected GMLOS, to ensure documentation identifies severity of illness and maximizes reimbursement potential.
• Coordinates and assures complete and accurate data collection and validation for public reporting data initiatives for Premier, CMS and JCAHO.
• Maintains good rapport and cooperative relationships. Approaches conflict in a constructive manner. Helps identify problems, offers solutions, and participates in their resolution.
• Coordinates with quality department by: providing concurrent review for core measures documentation, providing retrospective chart audits as needed, and educating nursing and medical staff of improvement and current status of quality initiates.
• Performs follow-up to document physician response to queries. Tracks and trends patterns of physician responses and reports monthly to director.
• Designs and implements collaboration with physician leadership specific tools to support medical record physician documentation.
• Review clinical issues with coding staff to assign working DRG’s.
• Work collaboratively with the coding staff to ensure that documentation of discharge diagnoses and co-morbidities are a complete reflection of the patient’s clinical status and care.
• Review final DRG and compare with clinical data gathered to ensure the DRG assigned is appropriated and that all co-morbidities are captured.
• Communicates with Case Management Director and/or Vice President of Medical Affairs regarding program barriers/success/outcomes of CDI program.
• Assists in collection and organization of data for analysis by appropriate medical and hospital committees.
• Consistently meets established productivity targets for record review.
• Maintain strict confidentiality at all time.
• Performs other duties as assigned. 

Requirements:

• Associate's Degree in Nursing
• RN License in state of employment or compact

Work Type:

Per Diem As Needed

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