PeaceHealth is seeking a RN Clinical Document Integrity Specialist for a Full Time, Day position.
Responsible for improving the overall quality and completeness of clinical documentation. Facilitates improvement to clinical documentation through extensive interaction with key stakeholders to ensure that appropriate reimbursement is received for the service rendered. Ensures the accuracy and completeness of clinical information used for measuring and reporting outcomes. Educates all members of the patient care team on an ongoing basis.
- Ensures the overall accuracy, completeness and timeliness of the clinical documentation to support the coding process in attaining the appropriate Diagnosis Related Groups (DRG).
- Ensure the completeness and accuracy of the clinical documentation by: formulating credible clarifications, conferring with providers to clarify clinical diagnosis terminology.
- Provide training to providers and caregivers to facilitate accuracy of clinical documentation, impact on coding and reimbursement and to improve methodologies to support data integrity.
- Review clinical documentation, identifies incomplete or inaccurate information for clinical relevance. Works with key stakeholders in a timely manner to ensure points of clarification are recorded in medical records, and appropriate DRG assignment completed to allow accurate coding and reimbursement.
- Act as a resource for best practices in clinical documentation, impact of Medicare guidelines and facilitates educating key stakeholders.
- Participates as a member of the CDI Task Force.
- Apply knowledge of current Medicare part A and how it impacts DRG assignment to the review of clinical documentation.
- Perform other related duties as assigned.
- Graduate of an accredited school/college of nursing is required.
- Ability to successfully pass a clinical competency exam.
- BSN or MSN preferred.
- Minimum 3 years recent acute care nursing (direct patient care) in hospital setting, either in Intensive Care, Critical Care or Medical /Surgical.
- Experience as a Clinical Documentation Specialist in a hospital program is preferred.
- Experience with JA Thomas and 3M 360 Encompass CAC software preferred.
- Knowledge of pathophysiology and disease process.
- Knowledge of value-based purchasing and other quality metrics affecting the clinical documentation integrity program.
- Current Registered Nurse licensure is required
- CCDS (Certified Clinical Documentation Specialist) preferred.
- CCRN (Critical Care Registered Nurse) certification preferred
- Strong verbal, written and interpersonal communication skills are required.
- Ability to interact effectively with providers and all levels of staff to achieve quality outcomes is required.
- Ability to effectively communicate clinical information is required.
- Ability to analyze/problem solve is required.
- Computer skills to include word processing, spreadsheet and data entry are required.
- Strong organization skills with the ability to work in a fast-paced environment independently and as part of an interdisciplinary team are required.
- Good critical thinking skills, able to assess, evaluate and teach are required.
- Working knowledge of all areas of adult medicine is required.
COMMUNITY/LOCATION SPECIFIC NOTES
- Additional Registered Nurse licensure may be required within one year of hire, for work performed in other states where PeaceHealth does business.
SHARED SERVICES PHYSICAL/COGNITIVE REQUIREMENTS:
- Work requires fairly light physical exertion from up to 65% of the time.
- Ability to lift objects weighing 30 lbs. or less.
- Work is performed under normal working conditions with adequate lighting and ventilation.
- Job duties frequently require intense concentration and attention to detail (up to 65% of work time).
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For full consideration of your skills and abilities, please attach a current resume with your application. EEO Affirmative Action Employer/Vets/Disabled in accordance with applicable local, state, or federal laws.