Registered Nurse (RN) Specialist, Clinical Documentation

Lifepoint Health • Hickory, NC

11h • Remote

About The Position

Frye Regional Medical Center is part of Lifepoint Health, a diversified healthcare delivery network with facilities coast to coast. We are driven by a profound commitment to prioritize your well-being so you can provide exceptional care to others. As a Registered Nurse (RN) joining our team, you are embracing a vital mission dedicated to making communities healthier. Join us on this meaningful journey where your skills, compassion and dedication will make a remarkable difference in the lives of those we serve. How you will contribute A Registered Nurse (RN) who excels in this role: Accurately performs patient assessments and identifies patient needs Identifies and initiates appropriate nursing interventions Provides care appropriate to condition and age of the patient Performs timely and appropriate documentation relating to medical necessity in the medical record Responsible for completion and revision of the Interdisciplinary Care Plan for each patient Performs timely and accurate QI assessments 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.

Requirements

• Applicants should have a current state RN license.
• 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.
• 1-3 years of experience working in chart review procedures, typically acquired by work experience of a clinical documentation improvement specialist, utilization review nurse, or inpatient coder.

Nice To Haves

• Bachelors degree preferred but not required
• RHIA, RHIT preferred
• CCDS or CDIP preferred
• Prior experience with Microsoft Office Suite preferred
• Prior experience with clinical record review preferred
• Prior experience with CDI software 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.
• Adheres to chart review productivity standards.
• 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.
• Prepares and presents educational programs to all internal constituents related to clinical documentation issues and coordinates same with clinical staff, physicians, compliance, and coding staff.
• Makes regular reports of progress toward goals associated with clinical documentation improvement opportunities and operational improvement plans.
• Assumes responsibilities for following compliance guidelines with federal, state, and local regulations within the department.
• Participates in data collection to document findings and outcomes to drive quality improvement and improved clinical documentation.
• Works closely with case management, quality management, risk management, and medical staff credentialing to provide data related to key clinical indicators and operational metrics.
• Ability to establish cooperative working relationship with diverse groups and individuals, medical staff and other health care disciplines and interact with all levels of employees.
• 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.
• Conducts CDI on-boarding education of all new admitting physicians as part of the hospitals orientation program.
• 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.
• Provides a positive and professional representation of the organization.
• Promotes a culture of safety for patients and employees through proper identification, reporting, documentation and prevention.
• Maintains hospital and clinic standards for a clean and quiet patient environment to maintain a positive patient care experience.
• Maintains competency and knowledge of current standards of practice, trends, and developments in related scope of role or practice.
• Maintains compliance with organization's policies, as well as established practices, protocols and procedures of the position, department, and applicable professional standards.
• Complies with organizational and regulatory policies for handling confidential patient information.
• Demonstrates excellent customer service through his/her attitude and actions, consistent with the standards contained in the Vision, Mission, and Values of the organization.
• Participates in patient rounding.
• Adheres to professional standards, hospital policies and procedures, federal, state, and local requirements, the TJC standards and or standards from other accrediting bodies.

Benefits

• Comprehensive Benefits: Multiple levels of medical, dental and vision coverage for full-time and part-time employees
• Financial Protection & PTO: Life, accident, critical illness, hospital indemnity insurance, short- and long-term disability, paid family leave and paid time off.
• Financial & Career Growth: Higher education and certification tuition assistance, loan assistance and 401(k) retirement package and company match.
• Employee Well-being: Mental, physical, and financial wellness programs (free gym memberships, virtual care appointments, mental health services and discount programs).
• Professional Development: Ongoing learning and career advancement opportunities.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Number of Employees: 101-250 employees