RN Clinical Document Specialist

Job ID: J120262
Company: Saint Vincent Health Center
Location: Erie, PA, United States
Facility: Saint Vincent Hospital
Full/Part Time: Full time
Job Type: Regular
Posted at: Apr 24, 2018

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Description

GENERAL OVERVIEW:

Improves the overall quality and completeness of medical documentation; facilitates enhancements to clinical documentation through extensive interaction with physicians, nursing staff, case managers, other patient caregivers, and medical records coding staff to ensure that the appropriate reimbursement is received for the level of service rendered to all inpatients; ensures the accuracy and completeness of clinical information used for measuring and reporting physician and hospital outcomes; educates all members of the patient care team on an ongoing basis.

ESSENTIAL RESPONSIBILITIES:

  • Review inpatient medical records for identified payor populations and analyze clinical information to identify areas within the medical record for potential gaps in physician documentation. (35%)
  • Formulate credible clinical documentation clarifications to improve clinical documentation of principal diagnosis, co-morbidities, present on admission (POA) and/or quality measures. (35%)
  • Facilitate modifications to clinical documentation through extensive interaction with physicians, nurses and ancillary staff based on knowledge of DRG assignment, documentation strategies, and clinical documentation requirements. (10%)
  • Work collaboratively with coding professionals to assure documentation of discharge diagnoses and comorbidities are a complete reflection of the patient's clinical status and care. (10%)
  • Educates all internal customers on compliant documentation responsibilities, coding and reimbursement issues, as well as performance improvement methodologies. (10%)
  • Performs other duties as assigned or required.

QUALIFICATIONS:

Minimum

  • Bachelor's Degree
  • Current PA RN license
  • 5 years current clinical experience, preferably in critical care or strong medical/surgical background

Preferred

  • Master's Degree
  • Clinical Documentation Improvement Specialist and or Coding Certification
  • CDS experience
  • Coding experience and/or training

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.
EEO is The Law
Equal Opportunity Employer Minorities/Women/ProtectedVeterans/Disabled/Sexual Orientation/Gender Identity (http://www1.eeoc.gov/employers/upload/eeoc_self_print_poster.pdf)
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