RN-Clinical Documentation Spec (kaweahhealth)

Job Description

Kaweah Health is a publicly owned, community healthcare organization that provides comprehensive health services to the greater Visalia area in central California. With more than 5,000 employees, Kaweah Health provides state-of-the-art medicine and high-quality preventive services in our acute care hospital, specialized health centers and clinics. Our eight-campus healthcare district has 613 beds and offers comprehensive health services across a broad continuum of care.   

It takes a special person to work for Kaweah Health. We serve a region where the needs are great, which makes the rewards even greater. Every day, we care for people facing unique challenges and in need of healing. Throughout it all, our focus is to make a difference, and we do — in the health of our patients, our loved ones, and our community.

Benefits Eligible

Full-Time Benefit Eligible

Work Shift

Day - 8 Hour or less Shift (United States of America)

Department

8792 Documentation

The Clinical Documentation Specialist (CDS) completes concurrent review of inpatient medical records to improve overall quality and completeness of clinical documentation.

QUALIFICATIONS

License /Certification

Required:

CA Registered Nurse license

BLS

Preferred: Clinical Documentation Certification

Education
Preferred: BSN, MSN, or currently enrolled in RN-BSN program.

Experience

Required: Minimum of three years hospital clinical experience

Preferred: Case/Utilization Management experience

Knowledge/Skills/Abilities
Excellent verbal and organizational skills
Computer literacy required

JOB RESPONSIBILITIES

Essential

Under the direct supervision of the Clinical Documentation Supervisor, responsible for improving the overall quality and completeness of clinical documentation.

Facilitates modifications to clinical documentation through extensive concurrent interaction with physicians, nursing, ancillary staff and coding staff to support that the appropriate reimbursement and clinical severity is captured for the level of services rendered to all patient s with DRG based payers.

Supports timely, accurate and complete documentation of clinical information used for measuring and reporting physician and Hospital outcomes.

Assists physicians and Licensed Independent Practitioners (LIPs), their office staff, Case Management and other hospital personnel with coding and DRG questions.

Reviews 85% of Medicare, Medicare Managed Care, and other designated DRG admissions for completeness of physician's clinical documentation using clinical documentation guidelines, clinical assessment and ICD-9-CM, ICD-10-CM, and DRG guidelines.

Monitors and completes cases in a timely manner.

Documents cases in the electronic clinical documentation software. Runs administrative reports as requested.

Confers with physicians and LIPs face to face or via query sheet to clarify information, obtains needed documentation, presents opportunities to educate regarding the significance of appropriate documentation needed to support the clinical severity of the patient.

Confers with Coders concurrently to ensure appropriate DRG assignment and completeness of supporting documentation. Attends coding meetings.

Assists in screening process, making referrals, interacting with case managers, social workers, and LIPs to ensure continuity of patient care.

Provides education (verbal and written) to Medical Staff members and committees as needed.

Tracks physician response to Clinical Documentation Improvement (CDI) initiatives and implements action plans for improvement.

Attends coding meetings as scheduled.

Refers coding and DRG questions to the Clinical Documentation Supervisor or Coding Manager as necessary.

Attends CDI Task Force meetings as scheduled and participates in ad hoc committees as necessary.

Responsible for DRG Assurance.

Addendum (essential for specific dept)

OUTPATIENT CDI

Must be devoted to ongoing, continuous learning in clinical medicine; practical understanding of ICD-10. Ability to educate physicians on the merits of best practice strategy for ICD-10 in their office and hospital setting; relevant updates and happenings in the business of medicine directly impacting physician’s, updates from CMS carriers effecting physicians such as billing, documentation and coding guidelines and policies. May be required to work flexible hours in order to facilitate face to face meetings with physicians in the hospital, ED, clinics, and eventually in their private practice. Accurately reflects and reports the patient’s severity of illness equating to intensity of service. Effectively demonstrates physician clinical judgment and medical decision making in support of medical necessity. Familiarity with MS-DRGs and the Inpatient Prospective Payment System (IPPS) including new CMS guideline of key elements including clinical documentation of what constitutes an inpatient admission. Strong clinical knowledge and demonstrated commitment to maintaining relevancy in clinical field. Familiarity with ICD-10 CM official coding guidelines. General knowledge of what constitutes a complete and accurate record- i.e. complete and thorough clinical documentation beginning with clear clinical documentation that supports medical necessity for a clinic visit and/or the ED reflective of clinical presentation of patient; reason for admission that clearly establishes and meets medical necessity criteria; need for continued stay in the hospital including response to treatment, interventions, and outcomes. Practical knowledge and understanding of official physician E&M guidelines and documentation requirements in support of proper E&M assignment and establishment of medical necessity. Effective ability and willingness to communicate benefits of complete and accurate documentation to physicians relating to their daily practice of medicine. Willingness to work with coding and chargemaster team to seek out lost revenue within certain departments in the outpatient realm. Willingness to work with physicians, RNs, and ancillary staff to develop new system processes and be able to tailor education and learning opportunities to each physician specialty as needed.

Additional

The nurse's practice is guided by the Code for Nurses. Decisions and actions on behalf of patients/residents are determined in an ethical manner. Maintains patient confidentiality within legal and regulatory parameters. Acts as a patient/resident advocate and assists patients/residents in developing skills so they can advocate for themselves. Delivers care in a nonjudgmental and nondiscriminatory manner that preserves patient autonomy, dignity and rights.

Demonstrates the knowledge and skills necessary to provide care and services appropriate to the population served on the assigned unit or work area. Knowledgeable of growth and development for all patient/family cultural, linguistic, spiritual, gender, and age specific needs. Able to effectively communicate and care for patient and family as reflected in the Plan for Provision of Care.

Performs other duties as assigned.

Pay Range

$45.53 -$68.30

If you want to use your talents alongside people who face each day with courage and purpose, in an environment that empowers you to do your absolute best, this is where you belong.