Compliance Documentation Improvement Specialist (RN) CMC Hybrid FT Days
About The Position
Assists treating providers to ensure documentation in the medical record accurately reflects the severity of illness of the patient as well as the level of service rendered. Uses clinical/nursing knowledge and understanding of national coding guidelines and standards of compliance to improve overall quality and completeness of clinical documentation within the patient electronic medical record using a multidisciplinary team process. Works collaboratively with physicians and advanced practice providers to ensure the clinical information within the medical record is accurate, complete, and compliant. Educates members of the patient care team both formally and informally regarding documentation guidelines, coding requirements and service specific requirements.
Requirements
- Registered Nurse North Carolina Licensure required.
- Bachelor's Degree Required.
- Appropriate professional certification required within 3 years of hire date per department protocol.
- 5 years of related nursing experience preferred.
- Clinical experience within the assigned population.
- Extensive knowledge of disease processes and clinical outcomes.
- Ability to speak English fluently and write in understandable terms.
Nice To Haves
- Case Management experience or background helpful.
- Strong financial and analytical skills preferred.
- Word, Outlook, Excel experience preferred.
Responsibilities
- Reviews selected populations of inpatient medical records to identify the principal and/or secondary diagnoses.
- Appropriately assigns the MS-DRG that most accurately reflects the severity of illness of the patient based upon the clinical evidence documented at the time of the record review.
- Demonstrates knowledge and understanding of severity based DRG systems; All Patient Refined and Medicare Severity (AP-DRG) and Medical Severity Diagnostic Related Group System (MS-DRG).
- Demonstrates the ability to utilize the licensed software tool to perform and record daily medical record reviews.
- Interacts with the physician and/or other designated members of the healthcare team to ensure that vague or incomplete documentation is clarified within the medical record in a timely manner.
- Works with other departments such as coding, corporate compliance, quality, and finance to support Corporate Goals.
- Participates in the ongoing education of physicians, nurse practitioners, physician assistants and other healthcare team members to identify medical record documentation improvement opportunities employing conflict resolution skills as necessary.
- Utilizes critical thinking skills based upon extensive knowledge of disease processes and clinical outcomes to identify the need for further clarification of physician documentation within the medical record.
- Ensures that 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 and other financial wellness programs
- Educational Assistance Program
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Number of Employees
11-50 employees
