Position Title: RN CLINICAL DOCUMENT SPEC III

Internal Close Date: 02/28/2017
Requisition Number: 13673832
Position Code: 1035
Department: HIM Clinical Documentation
FTE Status: 1
Position Type: BUDGETED
Shift: Days
Salary Range: Market competitive, based on experience

Position Summary:
Responsible for concurrent review of appropriate and complete clinical documentation in the electronic medical record to support services ordered and/or received, support primary diagnosis, secondary diagnoses, and co-morbidities to improved medical record physician documentation to appropriately support the severity of patient illness and resource consumption. Utilization of abstracting and data entry software tools to perform coding, abstracting and reporting functions. Provide training for caregivers in appropriate clinical documentation as indicated. Indirectly assures case mix index, DRG assignment and severity/mortality profiles are accurate. Ensure adherence to Hospitals and departmental policies and procedures. No patient care assignment.
Accountability:
  • REVIEW: In collaboration with the physician, nurse, patient care coordinator, and certified coding specialist (CCS), identify and record principle diagnoses, secondary diagnoses, procedures, and assign a working MS-DRG. Present results as individual teaching case reviews to the attending physician(s) and/or department or division members

  • CONCURRENT REVIEW - Conduct initial concurrent review and ongoing re-reviews for all selected admissions to initiate the tracking process, document findings on the MS-DRG worksheets, and identify other key quality indicators as appropriate

  • COMPLIANCE - Identify the need to clarify documentation in medical records and initiate communication with physician, nurse, or patient care coordinator by utilizing the appropriate “query” tools in order to capture the documentation in the medical record that accurately supports the patient’s severity of illness

  • PROBLEM-SOLVING - Interpret clinical information in the medical record, evaluate medications, vital signs, surgical outcomes, etc. Identify potential diagnoses based on this information and communicate with physicians to obtain appropriate documentation that most accurately reflects patient severity, risk of mortality, length of stay. Train providers in the art of appropriate diagnosis descriptions to capture the abnormal signs and symptoms treated for all complications and co-morbidities for each patient as part of their normal documentation

  • ABSTRACTS - Utilize monitoring tools to track the progress of the Documentation Improvement Program and identified quality indicator tracking elements, interpret tracking information and reports findings to the Health Information Management, Quality Management, and Utilization Review/Case Management meetings as requested. Identify department and/or specialty trends and patterns that show opportunities for improvements in documentations

  • PHYSICIAN COMMUNICATION – Participate in clinical rounding and other communication with physicians and residents on the inpatient units to obtain/clarify specific principal diagnoses or comorbidities and complications that pertain to the clinical information shared on specific patients during rounding; assist the rounding team with clarification of documentation appropriate that identifies diagnoses vs. ill-defined clinical symptoms Facilitate assertive, tactful communication when encountering resistance due to perception that information is adequately documented to achieve complete documentation per coding guidelines

  • COORDINATION - Coordinate and facilitate communication between Health Information Management, Utilization Review/Case management, Quality Management, physician leadership to acquire, interpret, and transmit accurate diagnostic and procedure documentation. Establish good working relationships with department Chairs and department Administrators to improve documentation

  • PROCESS IMPROVEMENT – Analyze baseline outcomes; develop process improvement plans to improve baseline to a higher level of performance; prioritize and implement process improvement action plans; monitor results, and present results in a way to capture provider interest and motivate change in documentation practices

  • REPORTS - Assist in the communication and distribution of physician profiling reports provided in conjunction with the Clinical Documentation Improvement Program software. Prepare Department and/or Division metrics reports for monthly meetings for areas assigned

  • REPORT ANALYSIS – Create appropriate reports to demonstrate improvements in major complication and comorbidity (MCC) and/or complication and comorbidity (CC) capture rates. Use report analysis to demonstrate missed opportunities to appropriately capture the true severity of illness patients

  • EDUCATION – Use query statistics and query type information to create training materials for physicians and ancillary staff. Identify opportunities for physician education to improve medical record documentation for severity of illness on an ongoing basis. Identify opportunities for coder education to improve coder query opportunities for MCCs and CCs

  • LEADERSHIP - Demonstrate strong clinical documentation leadership skills to become a valuable CDI specialist for medical departments and divisions assigned

  • CONFIDENTIALITY - Maintain confidentiality of patient records, adhering to HIPAA guidelines

  • Education Requirements:
  • MSN or Master's in a related discipline with certification in HIM/HIT

  • Experience Requirements:
  • 3 years directly related experience

  • Licensure/Certification Requirements:
  • Licensed Registered Nurse (RN) in State of New Mexico or as allowed by reciprocal agreement by State of New Mexico

  • Certified Document Improvement Practitioner/Specialist (CDIP or CDIS)

  • Physical Demands Requirements:
  • Sedentary Work: Exerting up to 10 pounds of force occasionally (Occasionally: activity or condition exists up to 1/3 of the time) and/or a negligible amount of force frequently (Frequently: activity or condition exists from 1/3 to 2/3 of the time) to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and all other sedentary criteria are met.

  • Licensure/Certification Requirements - Preferred:
  • Certified Coding Specialist (CCS)

  • Professional licensure as appropriate to the clinical objectives of the unit:
  • Certified Coding Specialist (CCS)

  • Testing Requirements:
  • Tuberculin Skin Test required annually

  • Working Conditions Requirements:
  • Minor Hazard - physical risks, dirt, dust, fumes, noise