Registered Nurse, Clinical Documentation NonExempt

Lifepoint Health•Florence, AL

About The Position

Facilitates improvement in the overall quality, completeness, and accuracy of clinical documentation. Through concurrent interaction with physicians, case managers, coders and other health care team members, the Clinical Documentation Specialist, will strive to ensure comprehensive medical record documentation that reflects the clinical treatment, decisions, and diagnosis for all inpatients. Serving as a resource to all members of the health care team on documentation guidelines, this position will provide guidance and support, as well as assist with education and training related to improving clinical documentation. Reports to: Market Director of Health Information Management FLSA: Non-Exempt Education: Associate's Degree or equivalen in the field of nursing required, Bachelor's Degree Preferred License: Current RN or LPN/LVN, RHIA, RHIT or combination thereof Preferred Certifications: BCLS Required, CCDS or CDIP Preferred; Coders must have CS or CIC Required Skills Requires critical thinking skills, decisive judgment and the ability to work with minimal supervision. Must be able to work in a stressful environment and take appropriate action.

Requirements

Requires critical thinking skills, decisive judgment and the ability to work with minimal supervision.
Must be able to work in a stressful environment and take appropriate action.
Associate's Degree or equivalen in the field of nursing required
Current RN or LPN/LVN, RHIA, RHIT or combination thereof Preferred
BCLS Required
Coders must have CS or CIC

Nice To Haves

Bachelor's Degree Preferred
CCDS or CDIP Preferred

Responsibilities

Conducts daily reviews of inpatient medical records to identify missing, vague, and/or incomplete diagnoses and procedures.
Conducts timely follow-up reviews of clinical documentation to ensure that issues discussed and queries left in the medical record have been answered by the provider.
Utilizes coding and clinical expertise to identify opportunities and ensure the accuracy and completeness of clinical documentation used for measuring and reporting physician and hospital outcomes.
Queries physicians on specificity of procedures performed and diagnoses based on accepted coding guidelines, clinical expertise and LifePoint Hospitals query policy.
Tracks and trends specific opportunities for CDI process improvement through the utilization of metrics reports.
Assumes responsibilities for following compliance guidelines with federal, state, and local regulations within the department.
Acts as a strong advocate of the CDI program while educating physician, clinical, and other staff on the importance of clinically accurate documentation and the capture of data through ICD-10 coding.
Demonstrates understanding of the importance of non-leading queries and communications with providers.
Reviews clinical issues and identified query response concerns with physician champion/advisors.
Stays current with requirements of CMS Inpatient Prospective Payment Systems (IPPS), AHA Coding Clinic and Official Guidelines for Coding and Reporting related to ICD-10.
Works closely with case management, quality management, risk/compliance management, and medical staff to provide data related to key clinical indicators and operational metrics.
Works in conjunction with the Directors of Quality Improvement and Care Management, medical staff leadership and other health care disciplines to assure effective monitoring and successful completion of identified plans for improvement.
Safeguards the patient’s right to privacy by judiciously protecting information of the patient and medical record as per HIPPA guidelines.
Performs other duties as assigned.