Clinical Document Specialist Nursing Hours: M-F 8AM - 4:30PM Days - Full-time Paygrade/Wages/Salary Info: 76H -
Job Summary Collaborates with physicians, nursing staff, support staff, ancillary staff, Medical Director of Case Management, and Health Information Management (HIM) coding staff to improve quality and completeness of documentation related to care provided and coded. # Job Responsibilities Facilitates concurrent modifications to clinical documentation to insure commensurate reimbursement of clinical severity and services rendered to patients with a Diagnosis-Related Group (DRG) based payer. Supports timely, accurate, and complete documentation of clinical information used for measuring and reporting physician and facility outcomes. Serves as a resource for physicians to help link coding guideline and medical terminology to improve accuracy of patient severity of illness, risk or mortality, and final code assignment. Identifies the most appropriate principle diagnosis, co-morbid conditions, complications of care, and procedures on a concurrent basis utilizing International Classification of Diseases (ICD-10-CM) Official Guidelines for Coding and Reporting. Confers with physicians one-on-one or by written documentation clarification (query) for: a) clinical indicators of a diagnosis but no documentation of the condition b) clinical evidence for a higher degree of specificity or severity c) a cause-and-effect relationship between two conditions or organism d) an underlying cause when admitted with symptoms e) only the treatment is documented (without a diagnosis documented) f) present on admission (POA) indicator status. Monitors and evaluates effectiveness of concurrent chart review and documentation clarification outcomes. Ensures accurate data entry to maintain the integrity of outcomes and effectiveness of overall program. Reviews final DRG assigned by HIM coding staff to ensure accuracy and that no further opportunity exists for documentation clarification. Educates all members of the patient care team on documentation guidelines on an on-going basis. Provides physician on-going education related to CMS rules and regulations pertaining to documentation in the health. Qualifications Associate#s degree or higher or Diploma in Nursing required upon hire Bachelor#s degree or higher in Nursing required within 5 years of employment in this position A minimum of 4 years# relevant experience required RN - Licensed as a Registered Nurse. Eligible to practice nursing in the State of Kentucky required upon hire Skills and Attributes Requires critical thinking skills and decisive judgment. Works under minimal supervision. Must be able to work in a stressful environment and take appropriate action. Physical Demands Standing: Occasionally Walking: Occasionally Sitting: Frequently Lifting 0-25 lbs: Rarely Lifting 25-75 lbs: Never Lifting over 75 lbs: Never Carrying 0-25 lbs: Rarely Carrying 25-75 lbs: Never Carrying over 75 lbs: Never Pushing/Pulling 0-25 lbs: Rarely Pushing/Pulling 25-75 lbs: Never Pushing/Pulling over 75 lbs: Never Climbing: Rarely Bending/Stooping: Rarely Kneeling: Rarely Crouching/Crawling: Rarely Reaching: Occasionally Talking: Frequently Hearing: Occasionally Repetitive Foot/Leg Movements: Never Repetitive Hand/Arm Movements: Frequently Keyboard Data Entry: Frequently Running: Never Vision: Depth Perception: Frequently Vision: Distinguish Color: Frequently Vision: Seeing Far: Frequently Vision: Seeing Near: Frequently Owensboro Health Core Commitments INTEGRITY - We conduct ourselves with a high level of responsibility, reliability and honesty because we take seriously the trust of our patients and coworkers. RESPECT - We value and accept the unique talents and contributions of every patient, customer and team member in the Owensboro Health community. TEAMWORK - We build a spirit of connectivity and fellowship by striving together to overcome obstacles, surpass goals, celebrate accomplishments and plan the future. INNOVATION - We foster original ideas and creative solutions that improve our daily work and promote the mission of Owensboro Health. SERVICE - We focus on service to patients, customers and team members by anticipating their needs, thoughtfully meeting those needs and continually improving the quality of everything we do. EXCELLENCE - We reach beyond basic expectations to expand our knowledge and awareness, produce exceptional work and provide outstanding service.