Compliance Documentation Improvement Specialist

Role Overview

• Assists treating providers to ensure documentation in the medical record accurately reflects the severity of illness of the patient as well as the level of service rendered
• Uses clinical/nursing knowledge and understanding of national coding guidelines and standards of compliance to improve overall quality and completeness of clinical documentation within the patient electronic medical record using a multidisciplinary team process
• Works collaboratively with physicians and advanced practice providers to ensure the clinical information within the medical record is accurate, complete, and compliant
• Educates members of the patient care team both formally and informally regarding documentation guidelines, coding requirements and service specific requirements
• Reviews selected populations of inpatient medical records to identify the principal and/or secondary diagnoses
• Appropriately assigns the MS-DRG that most accurately reflects the severity of illness of the patient based upon the clinical evidence documented at the time of the record review
• Demonstrates knowledge and understanding of severity based DRG systems; All Patient Refined and Medicare Severity (AP-DRG) and Medical Severity Diagnostic Related Group System (MS-DRG)
• Demonstrates the ability to utilize the licensed software tool to perform and record daily medical record reviews
• Interacts with the physician and/or other designated members of the healthcare team to ensure that vague or incomplete documentation is clarified within the medical record in a timely manner
• Works with other departments such as coding, corporate compliance, quality, and finance to support Corporate Goals
• Participates in the ongoing education of physicians, nurse practitioners, physician assistants and other healthcare team members to identify medical record documentation improvement opportunities employing conflict resolution skills as necessary
• Utilizes critical thinking skills based upon extensive knowledge of disease processes and clinical outcomes to identify the need for further clarification of physician documentation within the medical record
• Ensures that all written requests to physicians for additional documentation support Corporate Compliance policies

Requirements

• Registered Nurse North Carolina Licensure required
• Bachelor's Degree Required
• Appropriate professional certification required within 3 years of hire date per department protocol
• 5 years of related nursing experience preferred
• Clinical experience within the assigned population
• Extensive knowledge of disease processes and clinical outcomes
• Case Management experience or background helpful
• Strong financial and analytical skills preferred
• Word, Outlook, Excel experience preferred

Benefits

• Paid Time Off programs
• Health and welfare benefits such as medical, dental, vision, life, and Short
• and Long-Term Disability
• Flexible Spending Accounts for eligible health care and dependent care expenses
• Family benefits such as adoption assistance and paid parental leave
• Defined contribution retirement plans with employer match and other financial wellness programs
• Educational Assistance Program