Clinical RN Document Specialist

Good Samaritan • Vincennes, IN

13d • Onsite

About The Position

This role works collaboratively with the healthcare team to facilitate documentation within the medical record that supports the accurate patient’s severity of illness and risk of mortality. The specialist identifies the need to clarify documentation of records and utilizes effective communication skills with physicians, case managers, nurses, coders, and other healthcare professionals. They collaborate with physicians, physician assistants, and nurses/case managers to identify principal diagnosis options and secondary diagnoses for Medicare patients. The specialist serves as a resource to physicians and others regarding issues related to the appropriateness of inpatient DRG assignment. They review records and work collaboratively with nurses and physicians to assure accurate documentation of quality indicators in the medical record, proactively taking actions to assure the information is appropriately documented. The role requires current knowledge of inpatient reimbursement systems and the ability to communicate this knowledge verbally and in writing to physicians, their staff, case management, and staff in the Health Information Department.

Requirements

• Registered Nurse (RN) license
• Knowledge of inpatient reimbursement systems
• Effective communication skills (verbal and written)
• Ability to collaborate with physicians, physician assistants, nurses, case managers, and coders

Responsibilities

• Works collaboratively with the healthcare team to facilitate documentation within the medical record that supports the accurate patient’s severity of illness and risk of mortality.
• Identifies need to clarify documentation of records and utilizes effective communication skills with physician, case managers, nurses, coders and other healthcare professionals utilizing appropriate tools to capture needed documentation.
• Collaborates with physicians, physician assistants, and nurses/case managers to identify principal diagnosis options and secondary diagnoses for Medicare patients.
• Serves and a resource to physicians and others regarding issues related to the appropriateness of inpatient DRG assignment.
• Reviews record and works collaboratively with nurses and physicians to assure accurate documentation of quality indicators in the medical record. Responsible for proactively taking actions to assure the information is appropriately documented.
• Demonstrates current knowledge of inpatient reimbursement systems and is capable of communicating this knowledge in both verbal and written forms to physicians, their staff, case management , and staff in the Health Information Department.
• Other duties as assigned.

What This Job Offers

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