Compliance Documentation Improvement Specialist (RN) Pineville Hybrid FT Days

American Addiction Centers • Charlotte, NC

79d • $37 - $56

About The Position

The position involves reviewing selected populations of inpatient medical records to identify principal and/or secondary diagnoses. The role requires the assignment of the MS-DRG that accurately reflects the severity of illness based on clinical evidence documented at the time of the record review. The candidate must demonstrate knowledge of severity-based DRG systems, including All Patient Refined and Medicare Severity (AP-DRG) and Medical Severity Diagnostic Related Group System (MS-DRG). The position also involves utilizing licensed software tools for daily medical record reviews and interacting with physicians and other healthcare team members to clarify vague or incomplete documentation. Collaboration with departments such as coding, corporate compliance, quality, and finance is essential to support corporate goals. The role includes participation in ongoing education for healthcare team members to identify documentation improvement opportunities and requires critical thinking skills based on extensive knowledge of disease processes and clinical outcomes.

Requirements

• Registered Nurse applicable state Licensure required.
• Bachelor's Degree Required.
• Appropriate professional certification required within 3 years of hire date.
• 5 years of related nursing experience preferred.
• Clinical experience within the assigned population.
• Extensive knowledge of disease processes and clinical outcomes.
• Case Management experience or background helpful.
• Strong financial and analytical skills preferred.
• Experience with Word, Outlook, and Excel preferred.

Responsibilities

• Review selected populations of inpatient medical records to identify principal and/or secondary diagnoses.
• Assign the MS-DRG that accurately reflects the severity of illness based on clinical evidence.
• Utilize licensed software tools to perform and record daily medical record reviews.
• Interact with physicians and healthcare team members to clarify vague or incomplete documentation.
• Collaborate with coding, corporate compliance, quality, and finance departments.
• Participate in ongoing education for healthcare team members regarding documentation improvement.
• Utilize critical thinking skills to identify the need for further clarification of physician documentation.
• Ensure all written requests to physicians for additional documentation support Corporate Compliance policies.

Benefits

• Paid Time Off programs.
• Health and welfare benefits such as medical, dental, vision, life, and Short- and Long-Term Disability.
• Flexible Spending Accounts for eligible health care and dependent care expenses.
• Family benefits such as adoption assistance and paid parental leave.
• Defined contribution retirement plans with employer match.
• Educational Assistance Program.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Bachelor's degree
• Number of Employees: 11-50 employees