Registered Nurse (RN) - Clinical Documentation Integrity Specialist I, Full-Time, Days

Prisma Health • Greenville, SC

9d • Onsite

About The Position

Inspire health. Serve with compassion. Be the difference. Job Summary The RN Clinical Documentation Improvement Specialist performs on-site medical record reviews, examining and assessing all patient documentation to ensure that all information including the illness diagnosis is accurate. This is accomplished by a concurrent and retrospective review of medical records. Responsible for the validation of diagnosis codes and the identification of missing diagnosis so that patient severity of illness is properly reflected in the medical record. Essential Functions All team members are expected to be knowledgeable and compliant with Prisma Health's purpose: Inspire health. Serve with compassion. Be the difference. Conducts concurrent medical record reviews of selected patient health records to address clarity, completeness, consistency and accuracy of clinical documentation. Employs the query process as needed to provide accurate documentation reflective of patient's severity of illness, risk of mortality, comorbid conditions, length of stay, principal diagnosis, and present on admission (POA) status. Completes the reconciliation process to ensure accurate coding reflective of patient's severity of illness, risk of mortality, comorbid conditions, length of stay, principal diagnosis, and present on admission (POA) status. Develops and maintains supportive, collaborative relationships with providers and health care team members to include education and follow up. Stay current with coding guideline changes, changes in treatment modalities, clinical disease indicators, and compliant query policies. Serves as a resource for co-workers, providers, and other support departments (coding, case management, quality, nutrition, etc.) Assigns a working DRG for health care team discharge planning and CDI use. Performs other duties as assigned

Requirements

• Education - Associate degree in Nursing, Health Information Management, or related field of study
• Experience - Two (2) years -adult medical/surgical/critical care/ER/PACU nursing coding or related experience
• In Lieu Of In lieu of the education and experience requirements noted above, the following combination of education, training and/or experience may be considered an equivalent substitution: MD/DO/PA/NP
• Required Certifications, Registrations, Licenses RHIA/RHIT/CCS/CIC/or Licensure in related field of study/ Holds a current RN compact/multistate license recognized by the NCSBN Compact State or is licensed to practice as an RN in the state the team member is working.
• Knowledge, Skills and Abilities Computer skills Communication skills with ability to interact with providers. General knowledge of IPPS, ICD10 Coding, MS-DRG/APR-DRG and HCPCS coding systems preferred

Nice To Haves

• General knowledge of IPPS, ICD10 Coding, MS-DRG/APR-DRG and HCPCS coding systems preferred

Responsibilities

• Conducts concurrent medical record reviews of selected patient health records to address clarity, completeness, consistency and accuracy of clinical documentation.
• Employs the query process as needed to provide accurate documentation reflective of patient's severity of illness, risk of mortality, comorbid conditions, length of stay, principal diagnosis, and present on admission (POA) status.
• Completes the reconciliation process to ensure accurate coding reflective of patient's severity of illness, risk of mortality, comorbid conditions, length of stay, principal diagnosis, and present on admission (POA) status.
• Develops and maintains supportive, collaborative relationships with providers and health care team members to include education and follow up.
• Stay current with coding guideline changes, changes in treatment modalities, clinical disease indicators, and compliant query policies.
• Serves as a resource for co-workers, providers, and other support departments (coding, case management, quality, nutrition, etc.)
• Assigns a working DRG for health care team discharge planning and CDI use.
• Performs other duties as assigned

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree