RN Clinical Documentation Specialist

St. Luke’s University Health Network • Allentown, PA

4d • Onsite

About The Position

The Clinical Documentation Specialist is responsible for the review of inpatient medical records to facilitate the accurate representation of the severity of illness. This involves extensive record review, interaction with physicians, HIM professionals and nursing staff. Active participation in team meetings and education of the clinical staff in clinical documentation improvement are key functions of the role.

Requirements

• Registered Nurse required
• Current license required
• Minimum five years of RN/licensed provider experience in adult inpatient medical-surgical or critical care with thorough understanding of disease processes.
• Background knowledge of HIM field helpful, with focus on MS-DRG reimbursement, AHA coding guidelines, and compliance.

Nice To Haves

• BSN preferred
• Will consider NP, PA, or physician.
• Prior clinical documentation specialist experience and credential preferred.

Responsibilities

• Following orientation period, meets established productivity targets for new and follow-up inpatient record reviews per day.
• Formulates credible clinical documentation clarifications in 360’ format to improve clinical documentation of principal diagnosis, co-morbid conditions, present on admission status, and quality initiatives that support patient’s severity of illness, risk of mortality and patient safety indicators.
• Maintains an accuracy rate of 94% or greater in identifying correct concurrent initial and possible DRG when 2 or more diagnoses meet definition of PDX; reconciles correctly after coding to reflect highest severity and relative weight; ensures documented conditions, clarifications, and coded diagnoses are clinically valid and compliant; conducts follow up reviews utilizing department approved case prioritization methods; and utilizes process flow map in both concurrent and post discharge processes.
• Utilizes effective and appropriate verbal and written communication with physicians and other providers of record to validate observations and clarify additional and/or more specific documentation to accurately reflect the patient’s condition.
• Manages electronic communication efficiently and effectively.
• Demonstrates knowledge of International Classification of Diseases coding regulations, applies to ongoing evaluation of medical record documentation, and works closely with Coding staff to assure documented diagnosis (es) and co-morbidities gives a complete and compliant reflection of the patient's clinical status and care.
• Accurately inputs and analyzes data with the Clinical Documentation and performs re-reviews on a timely basis to identify changes in a patient’s condition through follow up or by writing new clarifications.
• Demonstrates competency in computer and network applications as necessary to perform role.
• Completes educational strategies to keep skills/knowledge current in documentation process and assists and supports with ongoing education for both formal and informal education of physician, nursing, and other clinical staff.
• Works collaboratively with healthcare team to facilitate documentation.
• Maintains good rapport and cooperative relationships.
• Approaches conflicts in a constructive manner.
• Helps identify problems, offers solutions, and participates in their resolution.

Benefits

• St. Luke's is proud of the skills, experience and compassion of its employees. The employees of St. Luke's are our most valuable asset! Individually and together, our employees are dedicated to satisfying the mission of our organization which is an unwavering commitment to excellence as we care for the sick and injured; educate physicians, nurses and other health care providers; and improve access to care in the communities we serve, regardless of a patient's ability to pay for health care.

What This Job Offers

• Job Type: Full-time
• Career Level: Senior