Job Description

RN Clinical Documentation Specialist

Day Shift (Hours: M-F 8 hours) Hybrid / No Weekends or Holidays!

Newark, DE

Christiana Care Hospital is hiring a RN Clinical Documentation Specialist for improving the overall quality and completeness of clinical documentation within the inpatient medical record. This is a hybrid position with remote and onsite requirements.

The RN Clinical Documentation Specialist will facilitate modifications to clinical documentation through extensive concurrent interaction with physicians and the coding staff to support that the appropriate reimbursement and clinical severity are captured compliantly for the level of service rendered to all patients with DRG-based payer. Supports timely, accurate, and complete documentation of clinical information used for measuring and reporting physician and hospital outcomes. Educates members of the patient care team on documentation guidelines on an ongoing basis. Serves as a clinical resource for the HIM coding department.

PRINCIPAL DUTIES AND RESPONSIBILITIES:

• Concurrent review of inpatient medical records throughout the patient’s hospitalization. Analyzes clinical status of patient, current treatment and past medical history and identifies potential gaps in physician documentation.
• Communicates with physicians or other providers to validate observations and appropriately prompts for documentation, if necessary, either verbally or written.
• Demonstrates proficient knowledge of HIMS standards of coding and applies to ongoing evaluation of the medical record documentation.
• Identifies patients appropriate for the Hospital Quality Measures and prompts RN and physician for clinical documentation according to the accepted standards .
• Educates physicians and other key healthcare providers regarding clinical documentation improvement and the need for accurate and complete documentation in the health record.
• Reviews and clarifies clinical issues in the health record with the coding professionals that would support an accurate DRG assignment, severity of illness, and/or risk of mortality.
• Identifies trends and/or opportunities to improve clinical documentation. Presents opportunities and potential solutions to the clinical documentation initiative team.
• Attends coding/financial educational programs and regulatory educational programs and updates as necessary to maintain proficient knowledge base.
• Demonstrate the highest level of confidentiality and conducts self-according to AHIMA Code of Ethics and ACDIS Code of Conduct
• Performs assigned work safely, adhering to established departmental safety rules and practices; reports to supervisor, in a timely manner, any unsafe activities, conditions, hazards, or safety violations that may cause injury to oneself, other employees, patients and visitors.
• Performs other related duties as required.

EDUCATION AND EXPERIENCE REQUIREMENTS:

• Bachelor’s degree in nursing.
• DE RN licensed or RN Compact State License.
• Minimum of 3 years recent experience as a Registered Nurse in acute care, adult care setting preferred.
• RN experience in Cardiac, Critical Care, Med-Surg, and Oncology experience highly desirable.
• Clinical Documentation, Case Management, Performance Improvement, or Inpatient Coding experience highly desirable.
• Certified Clinical Documentation Specialist (CCDS is required in a year after eligibility.

KNOWLEDGE, SKILL, AND ABILITY REQUIREMENTS:

• Extensive knowledge of medical terminology, anatomy, physiology, pharmacology, and disease processes
• Knowledge of ICD and CPT coding nomenclature, UHDDS, and general coding principles
• Knowledge of CMS, JCAHO, and external regulatory and quality requirements.
• Knowledge of Performance Improvement Principles
• Ability to work efficiently independently.
• Ability to work well with others on all levels, displaying diplomacy and tact.
• Ability to utilize computer applications on various platforms.
• Ability to manage multiple projects with constant shifts in priority.
• Ability to plan and organize work assignments.

PHYSICAL DEMANDS:

Prolonged daily review of charts on computer screen

WORKING CONDITIONS:

Nursing Unit Environment – no patient contact

Normal Office Environment.

Frequent deadline situations

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