Registered Nurse - Clinical Documentation

HonorHealth • Phoenix, AZ

16h

About The Position

Looking to be part of something more meaningful? At HonorHealth, you’ll be part of a team, creating a multi-dimensional care experience for our patients. You’ll have opportunities to make a difference. From our Ambassador Movement to our robust training and development programs, you can select where and how you want to make an impact. HonorHealth offers a diverse benefits portfolio for our full-time and part-time team members designed to help you and your family live your best lives. Visit honorhealth.com/benefits to learn more. Join us. Let’s go beyond expectations and transform healthcare together. HonorHealth is one of Arizona’s largest nonprofit healthcare systems, serving a population of five million people in the greater Phoenix metropolitan area. The comprehensive network encompasses six acute-care hospitals, an extensive medical group with primary, specialty and urgent care services, a cancer care network, outpatient surgery centers, clinical research, medical education, a foundation, an accountable care organization, community services and more. With nearly 17,000 team members, 3,700 affiliated providers and close to 2,000 volunteers dedicated to providing high quality care, HonorHealth strives to go beyond the expectations of a traditional healthcare system to improve the health and well-being of communities across Arizona. Learn more at HonorHealth.com.

Requirements

• Associates in Nursing or Foreign Medical (MD) Graduate with extensive clinical background and current CDI or coding experience. Required and
• 5 years patient care in hospital setting Required and
• Registered Nurse (RN) - License State Licensure And/Or Compact State Licensure or Foreign Medical (MD) Graduate Required and

Nice To Haves

• Bachelors in Nursing or Master’s Degree in Nursing or other related field. Preferred
• 1 year Clinical Documentation Improvement or Coding Preferred and
• 2 years Utilization Review/Case Management Preferred and
• 7 years patient care in critical care or medical/surgical area Preferred
• Certified Clinical Documentation Specialist - Certification issued by the Association of Clinical Documentation Improvement Specialists (ACDIS) or Certified Documentation Improvement Practitioner (CDIP) issued by The American Health Information Management Association (AHIMA). Preferred

Responsibilities

• Performs concurrent and retrospective (as required) medical record review utilizing evidence-based knowledge, protocols, and criteria. Facilitates modifications to support clinical documentation of health team members to ensure that appropriate reimbursement is received for the level of service rendered to all patients with a focus on physician documentation, inpatients and DRG payors. Ensures the accuracy and completeness of clinical information used for measuring and reporting physician and Hospital outcomes. Conducts follow-up reviews of clinical documentation to ensure points of clarification have been recorded in the patient’s chart.
• Communicates and interacts with physicians and clinical staff, verbally and through the use of written communication tools, observations and recommendations to improve the overall quality and completeness of clinical documentation.
• Conducts follow-up reviews of clinical documentation to ensure points of clarification have been recorded in the patient’s chart. Tracks response to clinical documentation and trends completion of the process, e.g. DRG worksheets.
• Establishes cooperative and multidisciplinary relationships with physicians and health team members including successful problem resolution and acts as a resource to the health team members related to optimal documentation.
• Develops and implements formal and informal educational programs related to documentation opportunities, coding and reimbursement issues, as well as performance improvement methodologies for internal customers and physicians.
• Designs, generates and evaluates the effectiveness of reports and evaluation tools, in conjunction with the Clinical Analyst- ICCM, utilizing multiple data systems in order to analyze impact of the documentation improvement process.
• Analyzes and compiles accurate and complete data for statistical reporting and educational presentations.
• Analyzes, summarizes and documents outcomes of documentation improvement process for re-evaluation of ongoing program revisions. Participates as a member of work groups related to clinical documentation, utilization and compliance, if required.
• Assumes responsibility and accountability for incorporating the vision, values, mission and critical goals of the organization into job performance.
• Perform other duties as assigned.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree
• Number of Employees: 5,001-10,000 employees