PURPOSE OF JOB: Obtains appropriate clinical documentation through extensive interaction with physicians, nursing staff, other patient care givers, and Health Information Management coding staff to ensure compliant, and robust clinical documentation needed to support correct code assignment. Applies coding guidelines to ensure optimal reimbursement is received for the level of services rendered. Reviews physician documentation to optimize clinical information which is utilized in profiling and reporting outcomes to insure documentation integrity and accuracy. On an ongoing basis, educates all members of the patient care team on clinical documentation guidelines.

QUALIFICATIONS:

Education:

-Registered Nurse currently licensed in the state of PA with advanced clinical experience and extensive knowledge of complex disease processes with a broad based clinical experience in an inpatient setting.

-Certification in Clinical Documentation Improvement by AHIMA or AAPC preferred.

Experience:

-Minimum of 3 years clinical nursing experience in an acute care setting

-CDI experience preferred.

-BSN Required

Other Skills:

-Detail oriented

-Good problem solving skills

-Professional interpersonal/communication skills

ESSENTIAL FUNCTIONS:

-Demonstrates knowledge of clinical documentation requirements and guidelines in accordance with Coding Clinic, professional CDI publications, Core Measures and other hospital initiatives as required.

-Requires excellent communication skills, high level critical and analytical thinking skills, and problem solving in addition to good verbal and written communication and able to work independently.

-Improves the overall quality and completeness of clinical documentation by performing admission/continued stay reviews using clinical documentation guidelines.

-Updates CDR2 Computer System to reflect any changes in status, procedures/treatments, and conferring with physician to finalize diagnosis as well as, conducts follow up reviews of compliant documentation to ensure points clarification with the physician have been recorded in the patient’s chart.

-Enters and updates diagnoses in Meditech's Problem List per Department procedure.

-Identifies redundant, inconsistent or nonsensical information in the Physician Progress Notes and notifies appropriate physician representative of finding.

-Queries physicians/patient care providers via paper queries entered in Meditech or via Tiger Text to provide compliant documentation necessary to support clinical care and accurate DRG/APR-DRG grouping as well as maximized SOI and ROM scores

Job Type: Full-time

Pay: $33.00 - $47.00 per hour

Benefits:

• 401(k)
• Dental insurance
• Employee discount
• Health insurance
• Life insurance
• Paid time off
• Vision insurance

Schedule:

• 8 hour shift
• Monday to Friday

Work Location: In person

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