Clinical Documentation Specialist, 40 hr/wk, Days, M-F

Job Description

Responsible for facilitating improvement in the overall quality, completeness and accuracy of concurrent medical record documentation. Obtains and promotes appropriate clinical documentation through extensive interaction with physicians, other patient caregivers, and HIM coding staff in order to ensure that the clinical documentation completely and accurately reflects the level of service rendered to patients. Analyzes facility case mix financial data for benchmarking and performance improvement. Involved in physician awareness of documentation practices in relation to coding guidelines that support appropriate reimbursement.


MAJOR RESPONSIBILITIES:

1. Performs concurrent medical record reviews to facilitate complete and accurate documentation in the medical record
2. Communicates with the Medical Staff and other caregivers at all levels both verbally and in writing to educate and encourage appropriate documentation practices
3. Monitors DRG case mix outcomes and identifies opportunities for performance improvement
4. Remains competent in areas of clinical expertise and reimbursement regulations affected by standards of practice
5. Adheres to organizational policies and procedures
6. Adheres to Service Excellence Standards of Behavior

Pay Rate: Min $25.54 Mid $29.36

Minimum Requirements: Graduate of an accredited school of professional nursing. The nursing school must be accredited by either the 1) National League of Nursing Accrediting Commission (NLNAC) or the 2) Commission on Collegiate Nursing Education (CCNE). The school is also acceptable if it has been accepted into candidacy status for accreditation by either of these commissions. Bachelors Degree preferred.


LICENSURE/CERTIFICATION REQUIREMENTS: Current license to practice professional nursing in the state of Ohio. Professional certification recognized by the ANCC preferred. Case management certification preferred.


MINIMUM EXPERIENCE REQUIREMENTS: Minimum of three (3) years relevant clinical nursing experience which should include a combination of medical, specialty and/or surgical care in an acute care setting with Case Management or Utilization Review over the past two years desired. Knowledge of inpatient reimbursement methodologies, regulations, and coding

Shift: 40 hr/wk, Full Time, 7:00a 3:30p (M-F) & Variable