Clinical Documentation Improvement RN

UHS • Aiken, SC

9h

About The Position

Responsible for improving the overall quality and completeness of clinical documentation. Promotes a partnership between the concurrent clinical reviewers, medical record coders, and physicians to improve documentation and reimbursement for ARMC. Facilitates clarification and specificity to clinical documentation through appropriate interaction with physicians, advocating for appropriate reimbursement. Supports the accuracy and completeness of the clinical information used for measuring and reporting physician and hospital outcomes to reflect the patient’s true severity of illness, intensity of care, and risk of mortality. Educates all members of the health care team on an ongoing basis.

Requirements

• Graduate of nursing program. BSN Preferred.
• Minimum of 5 years recent clinical experience in an acute care setting. Critical Care or Medical/Surgical preferred AND 3-5 years experience with inpatient coding and DRG guidelines.
• Registered Nurse with current S.C. license AND RHIA, RHIT, CDIP, CCDS or CCS preferred.
• Excellent written/verbal communication skills. Excellent critical thinking skills, must be detail oriented. Knowledge of age-specific needs and elements of disease processes and related procedures required. Strong broad-based clinical knowledge and understanding of pathology/physiology of disease processes. Ability to work independently in a time-oriented environment is essential. Working knowledge of Medicare reimbursement system and coding guidelines preferred. Computer literacy essential.

Responsibilities

• Provides concurrent review of the clinical documentation in the medical record and queries the medical staff as necessary via written/verbal communication to obtain accurate and complete physician documentation to support severity of illness and risk of mortality in the DRG Assurance program.
• Collaborates with physician, physician extender, nurse, case manager/utilization reviewer and Medical Records coder to identify principal diagnosis options, secondary diagnoses and procedures, to assign working DRGs for at least 85% of the identified populations. Able to utilize inpatient admission criteria to assign only diagnoses that meet acute care criteria.
• Completes the DRG worksheet and reviews documentation in the medical record according to schedule. Updates information in Documentation Improvement tracking system in a timely manner.
• Utilizes monitoring tools to track the progress of the DRG Assurance program, through interpretation of DRG tracking reports, monitoring reports and data. Shares findings with identified staff at DRG Assurance meetings. Able to identify areas of focus through report analysis. Serves as a resource to physicians and administration regarding issues related to the appropriateness of inpatient DRG assignment.
• Assists in the development of APR/DRG query response physician reports. Maintains complete confidentiality of patient information, in addition to hospital and individual physician practice pattern data.
• Performs other duties as assigned.

Benefits

• Unlimited Employee Referral Bonus Program
• Competitive Compensation & Generous Paid Time Off
• Excellent Medical, Dental, Vision and Prescription Drug Plans
• Tuition/Certification Reimbursement after 6 months
• Culture of Excellence – Employee Recognition program
• Challenging and rewarding work environment
• Clinical Nursing Ladder opportunities
• SoFi student loan refinancing program
• 401(K) with company match and discounted stock plan
• Career development opportunities within UHS and its 300+ Subsidiaries!

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Number of Employees: 501-1,000 employees