Requisition ID: 66642

Ministry: Corporate (LRHC and LPH)

Location: Presence St Joseph Chicago

Location Address:
2900 North Lake Shore Drive, Chicago, IL 60657 United States (US)

Department: 10153050 Central CDI

Daily Hours: 8
Standard Hours: 40
Employment Status: Full-time
Employment Type: Regular
Shift: Day
FLSA: E



SUMMARY

The Clinical Documentation Specialist - Registered Nurse ensures the overall quality and completeness of medical record clinical documentation. Facilitates modifications to clinical documentation through concurrent interaction with physicians, nursing staff, other patient caregivers, and health information coding staff to guarantee appropriate reimbursement and clinical severity is captured for the level of service rendered to all inpatients. Ensures timely, accurate and complete documentation of clinical information is used for measuring and reporting physician and hospital outcomes. Educates all members of the patient care team on an ongoing basis.



ESSENTIAL DUTIES AND RESPONSIBILITIES

Facilitates concurrent modifications to clinical documentation supporting appropriate reimbursement is received for the level of service rendered to inpatients.

Demonstrates knowledge of documentation opportunities, clinical documentation requirements and refers to policies and procedures.

Improves the overall quality and completeness of clinical documentation by performing continuous documentation/coding reviews using internal policies and procedures as well as Medicare guidelines. Ensures the accuracy and completeness of clinical documentation used for measuring and reporting physician and hospital outcomes.

Educates all internal customers, including physicians, nurses and other ancillary personnel, on clinical documentation opportunities, coding and reimbursement issues, as well as performance improvement methodologies. Prepares educational materials in support of training initiatives.

Conducts follow up reviews of clinical documentation to ensure points of clarification have been recorded in the patient's chart. Reviews clinical issues with coding staff and nurses to ensure appropriate inpatient technical diagnosis and procedural coding.

Performs ongoing inpatient documentation/monitoring and updates all staff on issues encountered. Provides corporate management with updates on coding/documentation issues for inpatient services

This document represents the major duties, responsibilities, and authorities of this job, and is not intended to be a complete list of all tasks and functions. Other duties may be assigned.

QUALIFICATIONS
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.


Education and/or Experience
Graduate of an accredited nursing program required. Minimum or five years clinical experience or three years of clinical experience and two years of ICD-9-CM Coding experience required.

Utilization review or coding experience is preferred.

Computer Skills
Knowledge of Microsoft applications (e.g., MS Windows, Outlook, Word) and Meditech required.

Midas experience preferred.

Certificates, Licenses, Registrations
Registered Nurse with a current Illinois License required.

*AC

Business Unit: Corporate (LRHC and LPH)
Department Name: Central CDI

Job Function: Nursing