Collaborates with physicians, nursing staff, Care Management and Health Information Management to improve quality and completeness of documentation of care provided and coded
Essential Job Duties:
Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions
- Facilitates modifications to clinical documentation to support appropriate reimbursement for the level of service rendered to all patients and to ensure completeness and accuracy of the medical record.
- Ensures accuracy and completeness of clinical information used for measuring and reporting physician and hospital outcomes.
- Educates internal customers on clinical documentation opportunities, coding and reimbursement issues, as well as performance improvement methodologies.
- Conducts follow-up reviews of clinical documentation to ensure points of clarification have been recorded in the patients chart; Works collaboratively with coding staff to assign DRGs; Tracks and trends response to CDI.
- Maintains thorough and current knowledge of clinical care and treatment of assigned patient populations to critically assess appropriateness of documentation.
- Graduate of an accredited RN program.
- At least 5 years' nursing experience in the acute care setting.
- Preferred: Utilization Review, coding or documentation improvement experience.
- RN with current Maryland Licensure
Working Conditions, Equipment, Physical Demands:
There is a reasonable expectation that employees in this position will not be exposed to blood-borne pathogens.
Physical Demands -
Light work. Exerting up to 20 pounds of force occasionally, and/or up to 10 pounds of force frequently, and/or a negligible amount of force constantly to move objects. If the use of arm and/or leg controls requires exertion of forces greater than that for sedentary work and the worker sits most of the time, the job is rated for light work.
The physical demands and work environment that have been described are representative of those an employee encounters while performing the essential functions of this position. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions in accordance with the Americans with Disabilities Act.
The above job description is an overview of the functions and requirements for this position. This document is not intended to be an exhaustive list encompassing every duty and requirement of this position; your supervisor may assign other duties as deemed necessary.