Registered Nurse (RN) - Clinical Documentation Specialist

Dartmouth Health • Lebanon, NH

123d

About The Position

The Clinical Documentation Specialist position is a full-time remote role that focuses on enhancing the quality, completeness, and accuracy of medical record documentation. The specialist will educate members of the patient care team on documentation guidelines and facilitate improvement in clinical documentation practices. This role is integral to ensuring that the severity of illness and level of services provided are accurately reflected in the medical records, which is crucial for appropriate reimbursement and compliance with regulations.

Requirements

• Must have the ability to create and maintain strong relationships and confidently discuss clinical diagnoses.
• Excellent verbal and written communication abilities required.
• Demonstrated interpersonal skills, including negotiation, conflict resolution, follow-through and follow-up.
• Must have good organizational skills including project management, with attention to detail and accuracy.
• Must possess the ability to develop and deliver clinical education programs on clinical documentation improvement for the Medical Staff and Hospital Staff.
• Must have the following computer competencies: data entry and analysis, word processing, and presentations.
• Knowledge of DRG prospective payment systems, documentation & coding guidelines and compliance requirements preferred.
• Current knowledge of DRGs and payment regulations preferred.
• Up-to-date clinical knowledge, understand clinical picture of the patient condition and identify opportunities for improved documentation.
• 3 years of applicable experience.

Nice To Haves

• CDI experience preferred.

Responsibilities

• Perform ongoing medical record reviews using documentation improvement guidelines.
• Evaluate overall quality and completeness of clinical documentation.
• Conduct follow-up reviews of clinical documentation.
• Initiate and maintain interactions with physicians and mid-level providers on a concurrent basis to address the need for more detailed information in the medical record.
• Ensure the severity of illness and level of services provided are accurately reflected in the medical record.
• Review clinical picture of the patient and assign a working DRG.
• Ensure the working DRG is entered in the appropriate database/IDX system and trends completion of DRG worksheets.
• Establish and maintain a system to track and analyze outcomes of documentation improvement program.
• Prepare regular outcomes progress reports and present them.
• Facilitate and participate in regular team meetings with the Coding staff.
• Work with inpatient coders to ensure appropriate DRG assignment and that reimbursement reflects the level of services rendered.
• Use performance improvement methodologies and education strategies to develop formal training and improvement programs for the staff concerning clinical documentation opportunities, coding and reimbursement issues.
• Provide ongoing updates as regulations change.
• Educate Coding team members on clinical (diagnostic and therapeutic) updates on an ongoing basis.
• Utilize nursing and clinical knowledge to respond to payors concerning clinical denials, as assigned.
• Provide clinical documentation expertise to assist in resolving outpatient issues involving physician documentation.
• Perform other duties as required or assigned.

Benefits

• Loan repayment up to $20,000.
• Generous tuition reimbursement.
• Popular 'earned time' plan.
• Extensive CEU/Training programs.
• Access to a state-of-the-art 8,000 ft Patient Safety and Training Simulation Center.
• Rigorous, research-focused environment.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Industry: Ambulatory Health Care Services
• Education Level: Bachelor's degree