Job Summary

Evaluates patients' medical records for appropriate documentation of all appropriate diagnoses. Utilizes clinical knowledge and coding guidelines to establish the appropriate diagnoses, reviews clinical reports and physician orders to identify undocumented conditions relative to the current hospitalization. Talks to and educates the physicians treating the patient on accurate and timely documentation of those conditions. in order to obtain, clarify or correct clinical documentation. Tracks case mix data to identify opportunities for documentation improvement in key areas. Works closely with coding department to insure concise and accurate documentation to support an accurate coding representation of patients clinical picture.

Responsibilities

• Read and interpret inpatient medical record entries to identify all diagnoses and surgical procedures. • Determine appropriate diagnostic and procedural sequencing in compliance with UHDDS guidelines. • Comply with HCFA's Medicare code edits. • Effectively utilize the appropriate features of Code3 Encoder/Grouper to identify opportunities for improving clinical documentation. • Talk to and educate physicians in the appropriate documentation of all diagnoses & procedures. • Ensures quality and accuracy of records for appropriate reimbursement. • Verifies & corrects any data discrepancies by initiating communication with physicians and other hospital personnel. • Participate in the quality improvement process. • Promote and enhance positive customer service and a positive work environment. • Promotes, identifies, and participates in providing physician education regarding the requirements of the Prospective Payment System. • Assists with improving record documentation practices to support diagnostic coding assignments. • Participate in case mix analysis. • Work closely with case coordinators to identify opportunities for improving clinical documentation. • Collaborate with the medical staff and serve as a resource expert regarding documentation.

Knowledge, Skills & Abilities

Patient Group Knowledge (Only applies to positions with direct patient contact) The employee must possess/obtain (by the end of the orientation period) and demonstrate the knowledge and skills necessary to provide developmentally appropriate assessment, treatment or care as defined by the department’s identified patient ages. Specifically the employee must be able to demonstrate competency in: 1) ability to obtain and interpret information in terms of patient needs; 2) knowledge of growth and development; and 3) understanding of the range of treatment needed by the patients. Competency Statement Must demonstrate competency through an initial orientation and ongoing competency validation to independently perform tasks and additional duties as specified in the job description and the unit/department specific competency checklist. Common Duties and Responsibilities (Essential duties common to all positions) 1. Maintain and document all applicable required education. 2. Demonstrate positive customer service and co-worker relations. 3. Comply with the company's attendance policy. 4. Participate in the continuous, quality improvement activities of the department and institution. 5. Perform work in a cost effective manner. 6. Perform work in accordance with all departmental pay practices and scheduling policies, including but not limited to, overtime, various shift work, and on-call situations. 7. Perform work in alignment with the overall mission and strategic plan of the organization. 8. Follow organizational and departmental policies and procedures, as applicable. 9. Perform related duties as assigned.

Education 

• Bachelor's Degree (Required) Experience: 5 - 7 YEARS Acute Care or Critical Care Nursing Experience SUBSTITUTION: Associate Degree in Nursing with 7-10 years Acute Care or Critical Care Nursing Experience. May substitute for Bachelor Degree in Nursing.

Credentials 

• Registered Nurse (Required)
• Cert Doc Improvement PracMust obtain within 3 yrs of hire

Work Schedule: Days

Status:  Full Time Regular 1.0

Location: Document Center Building

Location of Job: US:WV:Charleston

Talent Acquisition Specialist: Lauren R. Lane lauren.lane@vandaliahealth.org