RN Clinical Documentation Specialist

Role Overview

• Completes initial patient medical record review within 24-48 hours of patient's admission; completes subsequent reviews of patient's medical record reviews every 24-48 hours and enters review findings in CDE software system.
• Assigns Principal diagnosis, CC/MCC (complication and comorbidity/major complication and comorbidity), evaluate for Severity of Illness (SOI) and Risk of Mortality (ROM) on all patients while in-house.
• Assigns working ICD-10-CM and PCS codes and DRG (Diagnosis Related Group) using encoder in CDE software.
• Clarifies with physicians regarding missing, unclear, unsupported or conflicting health record documentation by requesting and obtaining additional documentation from physicians when needed.
• Educates key healthcare providers such as physicians, nurse practitioners, allied health professionals, nursing and care coordination regarding clinical documentation improvement, documentation guidelines and the need for accurate and complete documentation in the health record.
• Partners with coding professionals to ensure accuracy of diagnostic and procedural data and completeness of supporting documentation to determine the working and final DRG assignment.
• Reviews DRG denial letters and writes denial appeal letters.
• Collaborates with care coordination, nursing staff and other ancillary staff regarding interaction with physicians on documentation and to resolve physician clarifications prior to patient discharge.
• Maintains and upholds all clinical documentation regulatory guidelines.
• Formulates and submits timely, well prepared appeals for reconsideration by third party administrators (payors).

Requirements

• Minimum of five years acute care nursing experience with specific Pediatric/NICU experience.
• Excellent interpersonal skills including excellent verbal and written communication skills; proficient in and demonstrate excellent physician relations.
• Ability to organize and present information clearly and concisely; excellent computer and keyboarding skills; high degree of prioritization skills.
• Current RN Licensure.
• Certifications: CRCR Required within 9 months of hire.

Benefits

• Bonus Incentives
• Paid Certifications
• Tuition Reimbursement
• Comprehensive Benefits
• Career Advancement