Clinical Documentation Registered Nurse RN - Hybrid

JOB SUMMARY

Responsible for reviewing medical records to facilitate and obtain appropriate physician documentation for any clinical conditions or procedures to support the appropriate severity of illness, expected risk of mortality, and complexity of care of the patient, by improving the quality of the physicians’ clinical documentation. Exhibits a sufficient knowledge of clinical documentation requirements, MS-DRG Assignment, and clinical conditions and / or procedures.

Educates members of the patient care team regarding documentation guidelines, including the following : attending physicians, allied health practitioners, nursing, and case management.

ESSENTIAL DUTIES AND RESPONSIBILITIES

Include the following. Others may be assigned.

1. Record Review :

• Completes initial medical records reviews of patient records within 24-48 hours of admission for a specified patient population to : (a) evaluate documentation to assign the principal diagnosis, pertinent secondary diagnoses, and procedures for accurate MS-DRG assignment, risk of mortality and severity of illness; and (b) record in business partner designated CDI tool and / or host medical record system.
• Conducts follow-up reviews of patients every 24-48 hours or as needed up through discharge to support assigned working MS-DRG assignment upon patient discharge, as necessary.
• Formulate physician queries regarding missing, unclear, or conflicting health record documentation by requesting and obtaining additional documentation within the health record, as necessary.
• Collaborates with providers, case managers, nursing staff and other ancillary staff regarding documentation and to resolve physician queries prior to discharge.

2.CDI

3. Professional Development : Stays current with AHA Official Coding and Reporting Guidelines, CMS and other agency directives for ICD10-CM and PCS coding. Attends CDI Boot camp, CDI / coding trainings annually and quarterly for inpatient coding. Attends monthly education lecture series (MELS) and all CDI / coding assigned learn share modules as well as any additional required CDI education.

4. Assist in training department staff new to CDI

5. Performs other duties as assigned

KNOWLEDGE, SKILLS, ABILITIES

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill and / or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Conifer requires its candidates, as applicable and as permitted by law, to obtain and provide confirmation of all required vaccinations and screenings prior to the start of employment. This may include, but is not limited to, the COVID-19 vaccination, influenza vaccination, and / or any future required vaccines and screenings.

EDUCATION / EXPERIENCE

Include minimum education, technical training, and / or experience required to perform the job.

CERTIFICATES, LICENSES, REGISTRATIONS

PHYSICAL DEMANDS

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

WORK ENVIRONMENT

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

OTHER

Employment practices will not be influenced or affected by an applicant’s or employee’s race, color, religion, sex (including pregnancy), national origin, age, disability, genetic information, sexual orientation, gender identity or expression, veteran status or any other legally protected status. Tenet will make reasonable accommodations for qualified individuals with disabilities unless doing so would result in an undue hardship.

Tenet participates in the E-Verify program. Follow the link below for additional information.

E-Verify :

The employment practices of Tenet Healthcare and its companies comply with all applicable laws and regulations.

2503033002