Clinical Documentation Special (FT)

Columbus Regional Healthcare System • Whiteville, NC

10d

About The Position

Facilitates the improvement of clinical documentation and ensures accuracy of the level of clinical services and patient severity by conducting clinically based concurrent reviews of inpatient medical records to evaluate the clinical documentation of acute care services.  Works closely with the Medical Staff to facilitate appropriate physician documentation of patient care.  Responsible for reporting quality of care outcomes and in obtaining accurate and compliant reimbursement for acute care services.  Provides interdisciplinary education about regulatory and reimbursement changes.  Improves the physicians’ medical record documentation by addressing incomplete documentation through direct interaction with physicians.  Indirectly assures case mix index, Diagnostic Review Group (DRG) assignment and severity/mortality profiles are accurate by reviewing up to date reports and working closely with the Case Managers and Coders.  Develops concurrent education programs for physicians and other clinical staff to improve adherence to proper documentation.

Requirements

• BS in Nursing or Associate Degree in Nursing with documented experience in the fields of quality management, case management, utilization review with strong coding skills will be considered in lieu of BS.
• Current RN license from NC or compact state.
• 5 years acute care nursing experience.
• Knowledge of ICD-10-CM coding guidelines.
• Knowledge of regulatory guidelines and standards.

Nice To Haves

• BS in Nursing
• Prior case management experience is desirable.

Responsibilities

• Conduct clinically based concurrent reviews of inpatient medical records
• Evaluate the clinical documentation of acute care services
• Work closely with the Medical Staff to facilitate appropriate physician documentation of patient care
• Report quality of care outcomes
• Obtain accurate and compliant reimbursement for acute care services
• Provide interdisciplinary education about regulatory and reimbursement changes
• Improve the physicians’ medical record documentation through direct interaction with physicians
• Assure case mix index, Diagnostic Review Group (DRG) assignment and severity/mortality profiles are accurate by reviewing up to date reports and working closely with the Case Managers and Coders
• Develop concurrent education programs for physicians and other clinical staff to improve adherence to proper documentation

Benefits

• Competitive Pay Rates
• Company Swag
• Comprehensive Benefit Package
• Tuition Reimbursement
• Matching Retirement Plan
• Sign on Bonus (select positions)

What This Job Offers

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