RN - Clinical Documentation Integrity Specialist
Company Name:
PeaceHealth
Req ID:
12385
At PeaceHealth, we carry on the healing mission of Jesus Christ by promoting personal and community health, relieving pain and suffering, and treating each person in a loving and caring way. The fulfillment of this Mission is our shared purpose. It drives all that we are and all that we do. To those who embrace the spirit of these words and our commitment to Exceptional Medicine and Compassionate Care, we offer the opportunity to learn and grow as a member of the PeaceHealth family.
Department:
Clinical Documentation Integrity (8600)
JOB SUMMARY
Responsible for improving the overall quality and completeness of clinical documentation. Facilitates modifications to clinical documentation through extensive interaction with key stakeholders to ensure that appropriate reimbursement is received for the service rendered. Ensures the accuracy and completeness of clinical information used for measuring and reporting outcomes. Educates all members of the patient care team on an ongoing basis.
ESSENTIAL FUNCTIONS
1. Performs review of clinical documentation to include: review of admission/continued stays using best practices to facilitate obtaining and incorporating modifications from key stakeholders. Ensures the overall accuracy, completeness and timeliness of the clinical documentation to support the coding process in attaining the appropriate Diagnosis Related Groups (DRG) and the appropriate reimbursement is received for services rendered.
2. Ensures the completeness and accuracy of the clinical documentation by: formulating credible clarification, conferring with providers to clarify clinical diagnosis terminology and obtain needed documentation,
3. Provides training to providers and caregivers to facilitate accuracy of clinical documentation, impact on coding and reimbursement and to improve methodologies for capturing correct information.
4. Ensures the completeness and accuracy of the clinical documentation by: processing discharges to update the DRG worksheet to reflect changes in status, procedures/treatments and conferring with provider to finalize diagnoses.
5. Reviews clinical documentation for issues, identifies trends with incomplete or inaccurate information and clinical issues impacting coding or reimbursement. Works with key stakeholders in a timely manner to ensure points of clarification are recorded in patient charts, accurate DRG assignment and issues resolved for coding and reimbursement.
6. May assist in screening process, making referrals and interacting with care management to ensure continuity of patient care as needed; informs Care Management staff of changes in clinical diagnosis which impacts length of stay; uses knowledge of Intensity Severity Discharge (ISD) criteria to accurately document on worksheet for use by the Care Management staff.
7. Acts as a resource for best practices in clinical documentation, impact of Medicare guidelines, State, Federal and local regulations/laws to ensure compliance with coding standards which impacts clinical documentation and facilitates educating key stakeholders on changes.
8. Performs duties related to database management by: assisting with management of CDMPTrak; serving as a member of the CDMP Task Force.
9. Performs other related duties as may be assigned.
QUALIFICATIONS
EDUCATION:
Graduate of an accredited school/college of nursing is required.
Bachelor's degree in Healthcare Administration, Nursing or equivalent healthcare degree is preferred.
EXPERIENCE/TRAINING:
Minimum 3 years acute care nursing experience in hospital setting, preferably Critical Care or Medical /Surgical, or equivalent education and/or experience may be considered, as evidenced by sound critical thinking skills, ability to collaborate and communicate effectively with interdisciplinary care teams and leadership.
Minimum of 3 years' experience as a Compliance Documentation Specialist in a hospital program is preferred.
Prefer experience with JA Thomas software.
Knowledge of Diagnosis Related Groups is preferred.
LICENSE/CERTIFICATION:
Current Registered Nurse licensure in the state in which nurse will be practicing.
CCDS (Certified Clinical Documentation Specialist) preferred.
OTHER SKILLS:
Strong verbal, written and interpersonal communication skills are required.
Ability to interact effectively with providers and all levels of staff to achieve quality outcomes is required.
Ability to effectively communicate clinical information is required.
Ability to analyze/problem solve is required.
Computer skills to include word processing, spreadsheet and data entry are required.
Strong organization skills with the ability to work in a fast-paced environment independently or as part of an interdisciplinary team are required.
Good critical thinking skills, able to assess, evaluate and teach are required.
Working knowledge of all areas of adult medicine is required.
Location:
Longview, WA
Job Category:
IT/Health Information Management; Nursing - RN Other; Nursing - RN Patient Care
Shift:
Day
Shift Length:
8 Hours
FTE:
1.0
Work Type:
Full Time
Salary range starts at:
$33.84
Required Certifications/Licensure:
Registered Nurse - Washington
The above information on this description has been designed to indicate the general nature and level of work performed within this job class. It is not designed to contain or be interpreted as a comprehensive inventory of all duties, responsibilities, and qualifications required of caregivers assigned to this job.
To learn more about PeaceHealth, please visit us on Facebook or LinkedIn .
Posting Notes: Longview, WA -- IT/Health Information Management; Nursing - RN Other; Nursing - RN Patient Care -- Full Time -- HUMAN RESOURCES
Company Description:
As the premiere health care system in the Northwest, consistent with our mission and heritage, PeaceHealth is known for a healing culture that is patient-centered and family friendly. At PeaceHealth, the fulfillment of our Mission is our shared purpose. It drives all that we are and all that we do. To those who embrace the spirit of these words and our commitment to Exceptional Medicine and Compassionate Care, we offer the opportunity to learn and grow as a member of the PeaceHealth family. Join our team of caregivers who serve patients and their families to provide healing care for the mind, body and spirit.Estimated Salary: $20 to $28 per hour based on qualifications.
PeaceHealth
Req ID:
12385
At PeaceHealth, we carry on the healing mission of Jesus Christ by promoting personal and community health, relieving pain and suffering, and treating each person in a loving and caring way. The fulfillment of this Mission is our shared purpose. It drives all that we are and all that we do. To those who embrace the spirit of these words and our commitment to Exceptional Medicine and Compassionate Care, we offer the opportunity to learn and grow as a member of the PeaceHealth family.
Department:
Clinical Documentation Integrity (8600)
JOB SUMMARY
Responsible for improving the overall quality and completeness of clinical documentation. Facilitates modifications to clinical documentation through extensive interaction with key stakeholders to ensure that appropriate reimbursement is received for the service rendered. Ensures the accuracy and completeness of clinical information used for measuring and reporting outcomes. Educates all members of the patient care team on an ongoing basis.
ESSENTIAL FUNCTIONS
1. Performs review of clinical documentation to include: review of admission/continued stays using best practices to facilitate obtaining and incorporating modifications from key stakeholders. Ensures the overall accuracy, completeness and timeliness of the clinical documentation to support the coding process in attaining the appropriate Diagnosis Related Groups (DRG) and the appropriate reimbursement is received for services rendered.
2. Ensures the completeness and accuracy of the clinical documentation by: formulating credible clarification, conferring with providers to clarify clinical diagnosis terminology and obtain needed documentation,
3. Provides training to providers and caregivers to facilitate accuracy of clinical documentation, impact on coding and reimbursement and to improve methodologies for capturing correct information.
4. Ensures the completeness and accuracy of the clinical documentation by: processing discharges to update the DRG worksheet to reflect changes in status, procedures/treatments and conferring with provider to finalize diagnoses.
5. Reviews clinical documentation for issues, identifies trends with incomplete or inaccurate information and clinical issues impacting coding or reimbursement. Works with key stakeholders in a timely manner to ensure points of clarification are recorded in patient charts, accurate DRG assignment and issues resolved for coding and reimbursement.
6. May assist in screening process, making referrals and interacting with care management to ensure continuity of patient care as needed; informs Care Management staff of changes in clinical diagnosis which impacts length of stay; uses knowledge of Intensity Severity Discharge (ISD) criteria to accurately document on worksheet for use by the Care Management staff.
7. Acts as a resource for best practices in clinical documentation, impact of Medicare guidelines, State, Federal and local regulations/laws to ensure compliance with coding standards which impacts clinical documentation and facilitates educating key stakeholders on changes.
8. Performs duties related to database management by: assisting with management of CDMPTrak; serving as a member of the CDMP Task Force.
9. Performs other related duties as may be assigned.
QUALIFICATIONS
EDUCATION:
Graduate of an accredited school/college of nursing is required.
Bachelor's degree in Healthcare Administration, Nursing or equivalent healthcare degree is preferred.
EXPERIENCE/TRAINING:
Minimum 3 years acute care nursing experience in hospital setting, preferably Critical Care or Medical /Surgical, or equivalent education and/or experience may be considered, as evidenced by sound critical thinking skills, ability to collaborate and communicate effectively with interdisciplinary care teams and leadership.
Minimum of 3 years' experience as a Compliance Documentation Specialist in a hospital program is preferred.
Prefer experience with JA Thomas software.
Knowledge of Diagnosis Related Groups is preferred.
LICENSE/CERTIFICATION:
Current Registered Nurse licensure in the state in which nurse will be practicing.
CCDS (Certified Clinical Documentation Specialist) preferred.
OTHER SKILLS:
Strong verbal, written and interpersonal communication skills are required.
Ability to interact effectively with providers and all levels of staff to achieve quality outcomes is required.
Ability to effectively communicate clinical information is required.
Ability to analyze/problem solve is required.
Computer skills to include word processing, spreadsheet and data entry are required.
Strong organization skills with the ability to work in a fast-paced environment independently or as part of an interdisciplinary team are required.
Good critical thinking skills, able to assess, evaluate and teach are required.
Working knowledge of all areas of adult medicine is required.
Location:
Longview, WA
Job Category:
IT/Health Information Management; Nursing - RN Other; Nursing - RN Patient Care
Shift:
Day
Shift Length:
8 Hours
FTE:
1.0
Work Type:
Full Time
Salary range starts at:
$33.84
Required Certifications/Licensure:
Registered Nurse - Washington
The above information on this description has been designed to indicate the general nature and level of work performed within this job class. It is not designed to contain or be interpreted as a comprehensive inventory of all duties, responsibilities, and qualifications required of caregivers assigned to this job.
To learn more about PeaceHealth, please visit us on Facebook or LinkedIn .
Posting Notes: Longview, WA -- IT/Health Information Management; Nursing - RN Other; Nursing - RN Patient Care -- Full Time -- HUMAN RESOURCES
Company Description:
As the premiere health care system in the Northwest, consistent with our mission and heritage, PeaceHealth is known for a healing culture that is patient-centered and family friendly. At PeaceHealth, the fulfillment of our Mission is our shared purpose. It drives all that we are and all that we do. To those who embrace the spirit of these words and our commitment to Exceptional Medicine and Compassionate Care, we offer the opportunity to learn and grow as a member of the PeaceHealth family. Join our team of caregivers who serve patients and their families to provide healing care for the mind, body and spirit.Estimated Salary: $20 to $28 per hour based on qualifications.
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