Cath Lab RN Documentation Specialist / Scheduling RN - Bronson Methodist Hospital - Full-time Days

Bronson Healthcare • Kalamazoo, MI

7d • Onsite

About The Position

The RN-Clinical Documentation Specialist (RN-CDS) utilizes advanced coding knowledge, functional health patterns physiology, pathophysiology, and psychosociology to direct efforts toward the improvement of clinical documentation through the role of educator and consultant. The CDS facilitates improvement in the overall quality, completeness, and accuracy of medical record documentation through extensive record review. The focus of this role is to do a primary assessment of all documentation in the medical record. When finding deficits the RN-CDS coaches physicians regarding documentation improvements that will better reflect the patient’s true severity of illness and risk of mortality. This improved documentation can also optimize reimbursement that would otherwise be lost to the organization. The RN-Clinical Documentation Specialist gathers, does analysis of data and develops improvement plans for the identified documentation challenge. This could range from development of a tool to help capture the needed documentation to one on one coaching with a struggling provider. Clinical denials are becoming a more frequent focus of the insurance and regulatory agencies, the frequency and volume of these reviews has continued to increase. The RN-Clinical Documentation Specialist provide support to this process with record review, providing clinical evidence to support the original DRG billed, and assisting with letter writing. Employees providing direct patient care must demonstrate competencies specific to the population served.

Requirements

• Bachelor’s degree required
• recent clinical experience in an acute care setting (prefer experience in Critical Care, Medical/Surgical, Utilization Management/Case Management, and Patient Outcomes/Quality Management) required.
• Licensed Registered Nurse in good standing with the State of Michigan
• Must possess exceptional communication and interpersonal skills
• Must be self-directed and flexible
• Must demonstrate positive relationships with physicians and peers
• Must possess leadership abilities and promote collaboration
• Must be willing to accept high level of responsibility and accountability
• Must be able to move about hospital and between workstations, while maintaining positive interdepartmental relations.
• Must possess excellent clinical skills, advanced problem solving ability, and is able to role model and teach others in a non-threatening supportive manner.
• Must be knowledgeable of Bronson / Community systems related to assigned service line.
• Must be able to attend to detail without losing sight of overall goals or issues.
• Must be able to function effectively in a fluid, dynamic, and rapidly changing environment.
• Must be able to discern issues and maintain composure with physicians and staff.

Nice To Haves

• Master’s degree preferred.
• Prefer knowledge of reimbursement systems.

Responsibilities

• Responsible for clinical documentation analysis (Medical), documentation completeness, coding accuracy and compliance.
• Facilitates modifications to clinical documentation in order to support accurate hospital and physician billing.
• In order to present an accurate hospital and physician’s profile, all diagnoses and procedures must be documented in the medical record and must properly reflect the level of services being provided. Will work with individual physicians to achieve this goal.
• Acting as an expert clinical resource for the coding area.
• Timely communication with assigned service line physicians as well as multi disciplinary teams.
• Performs initial case reviews and appropriate follow-up reviews based on judgement of clinical picture.
• Performs accurate and timely concurrent reviews of the medical records of inpatient admissions to include assignments of DRG, identifying complication and co-morbid conditions and specific co-existing conditions.
• Documents findings on CDI system worksheets and verifies key clinical information, as appropriate.
• Improves the overall quality and completeness of clinical documentation by interpreting clinical information in the medical record, evaluating medications, vital signs, surgical outcomes, etc.
• Recognizes opportunities for documentation improvement. Works collaboratively with medical staff, nursing staff, and coding staff to improve the quality of chart documentation to accurately reflect risk of mortality, severity of illness, and services provided.
• Initiates communication with physicians, through verbal or electronic means, in order to obtain or offer more specific principal diagnosis or co-morbidities and complications. Solicits clarification of existing documentation in the medical record that supports patient’s risk of mortality and severity of illness.
• Collaborates with coding staff on meeting coding guidelines, interpreting tracking information and developing profiling by services in data review, and with physician education related to documentation requirements.
• Develops and presents pertinent information to appropriate administrative and medical staff departments/committees.
• Able to articulate and demonstrate commitment both to program goals and to the vision, values, and mission of Bronson.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level