Registered Nurse (RN) - Clinical Documentation Specialist, Remote

Dartmouth-Hitchcock Health•Lebanon, NH

6d•Remote

About The Position

The Clinical Documentation Specialist (RN) facilitates improvements in the quality, completeness, and accuracy of medical record documentation and educates members of the patient care team on documentation guidelines. The role conducts ongoing and follow-up medical record reviews, works concurrently with physicians and mid-level providers to obtain more detailed documentation, and helps ensure that the patient’s severity of illness and level of services are accurately represented in the record. The specialist reviews the patient’s clinical picture and assigns a working DRG, records it in the appropriate database or IDX system, and monitors completion of DRG worksheets. The role tracks and analyzes documentation-improvement outcomes, prepares progress reports, collaborates with Coding staff and inpatient coders, and provides education and training related to documentation, coding, reimbursement, and clinical updates. It also uses nursing and clinical knowledge to assist with payor clinical denials and outpatient documentation issues. This is a remote position at Dartmouth Health, with a schedule of 40 hours per week. CDI-specific experience is preferred. Dartmouth Health highlights loan repayment up to $20,000, tuition reimbursement, an earned-time plan, extensive CEU and training programs, shared governance, and a rigorous, research-focused environment.

Requirements

Licensed Registered Nurse with NH eligibility.
Three years of applicable experience.
Ability to create and maintain strong relationships and confidently discuss clinical diagnoses.
Excellent verbal and written communication abilities.
Demonstrated interpersonal skills, including negotiation, conflict resolution, follow-through, and follow-up.
Good organizational skills, including project management, with attention to detail and accuracy.
Ability to develop and deliver clinical education programs on clinical documentation improvement for Medical Staff and Hospital Staff.
Computer competencies in data entry and analysis, word processing, and presentations.
Up-to-date clinical knowledge and ability to understand the patient’s clinical condition and identify opportunities for improved documentation.

Nice To Haves

CDI-specific experience.
Knowledge of DRG prospective payment systems, documentation and coding guidelines, and compliance requirements.
Current knowledge of DRGs and payment regulations.

Responsibilities

Perform ongoing medical record reviews using documentation-improvement guidelines and evaluate the overall quality and completeness of clinical documentation.
Conduct follow-up reviews of clinical documentation.
Initiate and maintain concurrent interactions with physicians and mid-level providers to address the need for more detailed information in the medical record.
Ensure the severity of illness and level of services provided are accurately reflected in the medical record.
Review the patient’s clinical picture and assign a working DRG.
Enter the working DRG in the appropriate database or IDX system and track completion of DRG worksheets.
Establish and maintain a system to track and analyze documentation-improvement program outcomes; prepare and present regular progress reports.
Facilitate and participate in regular team meetings with Coding staff.
Work with inpatient coders to support appropriate DRG assignment and ensure reimbursement reflects the level of services rendered.
Use performance-improvement methodologies and education strategies to develop formal training and improvement programs for staff on clinical documentation opportunities, coding, and reimbursement issues.
Provide ongoing updates as regulations change.
Educate Coding team members on clinical diagnostic and therapeutic updates.
Use nursing and clinical knowledge to respond to payors concerning clinical denials, as assigned.
Provide clinical documentation expertise to help resolve outpatient issues involving physician documentation.
Perform other duties as required or assigned.