Clinical Documentation Improvement RN

Responsibilities

Clinical Documentation Improvement (CDI)

Auditor / RN

Aiken Regional Medical Centers, located in Aiken, South Carolina, is a 273-bed acute care facility providing top quality and safe healthcare to the residents of Aiken and surrounding communities since 1917. Aiken Regional Medical Centers has been ranked a top hospital in South Carolina by the American Heart Association for its treatment of heart attack, heart failure and Stroke, and most recently, coronary artery disease.

Additionally, Aiken Regional provides comprehensive healthcare services such as behavioral health ( Aurora Pavilion Behavioral Health ), emergency medical care (main hospital and ER at Sweetwater ), orthopedic surgeries, maternity, rehabilitation services( Hitchcock Rehabilitation Services ), imaging, and wound care.

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Position Description :

Responsible for improving the overall quality and completeness of clinical documentation. Promotes a partnership between the concurrent clinical reviewers, medical record coders, and physicians to improve documentation and reimbursement for ARMC. Facilitates clarification and specificity to clinical documentation through appropriate interaction with physicians, advocating for appropriate reimbursement. Supports the accuracy and completeness of the clinical information used for measuring and reporting physician and hospital outcomes to reflect the patient's true severity of illness, intensity of care, and risk of mortality. Educates all members of the health care team on an ongoing basis.

Duties :

• Provides concurrent review of the clinical documentation in the medical record and queries the medical staff as necessary via written / verbal communication to obtain accurate and complete physician documentation to support severity of illness and risk of mortality in the DRG Assurance program.
• Collaborates with physician, physician extender, nurse, case manager / utilization reviewer and Medical Records coder to identify principal diagnosis options, secondary diagnoses and procedures, to assign working DRGs for at least 85% of the identified populations. Able to utilize inpatient admission criteria to assign only diagnoses that meet acute care criteria.
• Completes the DRG worksheet and reviews documentation in the medical record according to schedule. Updates information in Documentation Improvement tracking system in a timely manner.
• Utilizes monitoring tools to track the progress of the DRG Assurance program, through interpretation of DRG tracking reports, monitoring reports and data. Shares findings with identified staff at DRG Assurance meetings. Able to identify areas of focus through report analysis. Serves as a resource to physicians and administration regarding issues related to the appropriateness of inpatient DRG assignment.
• Assists in the development of APR / DRG query response physician reports. Maintains complete confidentiality of patient information, in addition to hospital and individual physician practice pattern data.
• Performs other duties as assigned.

Benefit Highlights

About Universal Health Services

One of the nation's largest and most respected providers of hospital and healthcare services, Universal Health Services, Inc. (NYSE : UHS) has built an impressive record of achievement and performance, growing since its inception into a Fortune 500 corporation. Headquartered in King of Prussia, PA, UHS has 99,000 employees. Through its subsidiaries, UHS operates 28 acute care hospitals, 331 behavioral health facilities, 60 outpatient and other facilities in 39 U.S. States, Washington, D.C., Puerto Rico and the United Kingdom.

Qualifications

Requirements :

EEO Statement

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