Position Title: RN CLINICAL DOCUMENT SPEC

Internal Close Date: 04/07/2017
Requisition Number: 13725277
Position Code: 489
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 (during the patient stay) of appropriate and complete clinical documentation in the medical record to support services ordered and/or received, support primary diagnosis, secondary diagnoses, and co-morbidities to improve medical record physician documentation to appropriately support the severity of patient illness and resource consumption. Responsible for addressing and communicating appropriate documentation findings with physicians and other caregivers as necessary via written queries and/or verbal communication. Responsible for follow up to obtain accurate and complete documentation in the medical record during the hospitalization. Utilization of abstracting and data entry software tools to perform coding, abstracting and reporting functions. Provide training for providers on 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.

Related Education and Experience may be substituted for one another on a year for year basis.
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

  • 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 and risk of mortality

  • 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

  • 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 of illness

  • 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

  • PHYSICIAN COMMUNICATION - Communicate with physician to obtain/clarify specific principal diagnoses or comorbidities and complications; request clarification of existing documentation. 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. Inform Coding management of potential and/or actual problems

  • PROCESS IMPROVEMENT - Identify baseline outcomes; develop process improvement plans; prioritize and implement process improvement action plans; monitor and follow up on results

  • REPORTS - Assist in the communication and distribution of physician profiling reports provided in conjunction with the Clinical Documentation Improvement Program software

  • REPORT ANALYSIS - Through report analysis, review how documentation reflects severity of illness and report pertinent results to appropriate entities (e.g., physicians, committee, intra-departmental, etc.) Perform individual and group analysis of physicians and outcomes related to service line documentation issues

  • EDUCATION - Provide information and education necessary to physicians and ancillary staff not responding to “queries” for appropriate follow up and consequences thereof. 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 coding for severity of illness and morbidity

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

  • OTHER - Perform other duties as assigned

  • Certification Requirements:
  • RN MATRIX - Complete and maintain unit/clinic based required certifications and competencies as listed in the department expectations/and or the unit/clinic education matrix

  • Education Requirements:
  • Nursing program (nationally accredited) graduate

  • Experience Requirements:
  • 1 year 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

  • Education Requirements - Preferred:
  • Bachelor's Degree of Science in Nursing

  • Experience Requirements - Preferred:
  • Documentation improvement experience

  • Physical Demands Requirements:
  • Light Work: Exerting up to 20 pounds of force occasionally, and/or up to 10 pounds of force frequently, and/or a negligible amount of force constantly (Constantly: activity or condition exists 2/3 or more of the time) to move objects. Physical demand requirements are in excess of those for Sedentary Work. May require walking or standing to a significant degree or requires sitting most of the time but entails pushing and/or pulling of arm or leg controls; and/or may require working at a production rate pace entailing the constant pushing and/or pulling of materials even though the weight of materials is negligible.

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

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

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

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

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

  • May be required to work rotating shifts, holidays and weekends