Mercy Health RN Clinical Documentation Specialist in Warren, Ohio
RN Clinical Documentation Specialist
Job ID: 4652187
Updated: August 11, 2017
Geographic Location: Youngstown
Location: Warren, OH, United States
Department: Rev Cycle HO & Suppt Services
Full/Part Time: Full-Time
Standard Hours: 40
Facilitates improvement in the overall quality, completeness and accuracy of medical record documentation. Obtains and promotes appropriate clinical documentation through extensive interaction with physicians, nursing staff, other patient caregivers and Health Information Management coding staff to ensure clinical documentation reflects the level of service rendered to patients is complete and accurate. Educates all members of patient care team on documentation guidelines, on an on-going basis.
Essential Functions & Responsibilities:
It is expected that all of the Principal Duties and Responsibilities identified below will be performed in a manner that reflects the values of the Mercy Health, which are: Excellence, Human Dignity, Justice, Compassion, Sacredness of Life and Service.
- Facilitates appropriate clinical documentation to ensure the level of services and acuity of care are accurately reflected in the medical record.
- Performs admission reviews for specific patient populations using clinical documentation guidelines.
- Assists in medical screening process by documenting appropriateness of patient admission, working DRG & LOS info on worksheet and computer system as appropriate.
- Extensively reviews all physician and clinical documentation, lab results, diagnostic information, and treatment plans and captures appropriate information on CDMP® worksheet.
- Utilizes clinical skills to identify documentation opportunities that reflect severity of illness, acuity and resource consumption.
- Verbally communicates with appropriate physician(s) to ensure documentation opportunities are clarified.
- Communicates with ancillary personnel (e.g., PT, ET) to clarify potential documentation opportunities.
- Updates DRG worksheet to reflect any changes in patient status, procedures/treatments, and confers with physician to finalize diagnoses.
- Reviews medical record every 24-48 hours as appropriate.
- Updates Clinical Documentation Management Program worksheet to reflect additional physician documentation, lab findings, diagnostic test results and treatment as appropriate.
- Updates Clinical Documentation Management Program worksheet to reflect any changes in DRG assignment.
- Communicates with physician to ensure that request for documentation has been noted.
- Confers with physician to establish appropriate severity of illness and ensure documentation of principal diagnosis, comorbid conditions, complications and procedures.
- Conducts follow-up reviews of clinical documentation to ensure issues discussed and clarified with the physician have been documented in patient’s chart.
- As appropriate, documents, analyzes data and reports instances of inappropriate patient care, discharge delays, etc. to Manager of Health Records Services
- Collaborates with coding staff as needed to determine appropriate DRG and required documentation.
- Provides clinical expertise and references to the coding staff.
- Stays current with and conducts on-going clinical documentation management program education for new staff, including new clinical documentation specialists, physicians and nursing and allied health professionals. Tracks and trends program compliance.
- Attends and participates in weekly educational conferences.
- Participates in concurrent performance improvement activities and on-going MR review activities.
- Maintains positive and open communications with physicians, interdisciplinary care team members, coding staff, Regional Manager of Coding, Quality and Compliance.
Knowledge, Skills & Experience Required:
Registered Nurse (RN) with 5 years’ experience in med/surg, critical care, intensive care or emergency room care preferrerd.
Excellent interpersonal skills including excellent verbal and written communication skills; proficient in and demonstrate excellent physician relations
Must possess and consistently demonstrate strong interpersonal communication skills.
Ability to organize and present information clearly and concisely; excellent computer and keyboarding skills; high degree of prioritization skills
Must be computer literate or willing to learn how to use computer applications relative to job
Must possess analytical and organizational skills and be self motivated. Must be able to handle stressful situations in a professional constructive manner.
Achieve 70% or greater on JA Thomas's Clinical Competency Assessment.
Full-time, days, 40 hours per week, 7:00 a.m. to 3:30 p.m.
Weekdays with Saturday rotation. No holidays.
Equal Employment Opportunity
It is our policy to abide by all Federal and State laws, as well as, the requirements of 41 CFR 60-1.4(a), 60-300.5(a) and 60-741.5(a), prohibiting discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibiting discrimination against all individuals based on their race, color, religion, sex, sexual orientation, gender identity, or national origin.