JOB SUMMARY
Reviews patient medical records and assesses whether all conditions and treatments are documented. This reflects a clear accurate and complete picture of the resources utilized for the care received and how complex the condition of the patient. Clinical Documentation Integrity Specialists query physicians when documentation is unclear or deficient. Clinical Documentation Integrity Specialists serve as the bridge between Health Information Management, Coding and clinical staff. Practices with minimum supervision from another licensed professional. Not a patient facing position.
Qualifications
JOB QUALIFICATIONS
Education: Graduate of an accredited School of Nursing, BSN preferred
Licensure: Current RN Nursing License. AHA, BLS, CPR is preferred.
Experience: Three to Five years of nursing experience as an RN with two years of recent clinical experience. Utilization Review experience is preferred. Computer skills experience required.
Skills:
* Must possess a high level of clinical knowledge regarding the patient population served, to participate collaboratively with all members of the care team.
* Must have strong critical thinking skills and exceptional ability to integrate knowledge
* Excellent observation, communication, and decision making abilities
* Ability to assess, evaluate, and teach all members of the care team
* Working knowledge of DRG coding and documentation strategies
* Thorough knowledge of clinical documentation requirements
* Ability to prioritize multiple tasks simultaneously
* Ability to work proficiently with computer systems, including work effectively, including work processing and database software as necessary.
* Organizational skills with ability to communicate effectively, verbally, and in writing, and interact with levels of professions, including but not limited to physicians and nursing personnel, managers, and various support staff departments, and third party payers in a non-confrontational manner
PHYSICAL, MENTAL, ENVIRONMENTAL AND WORKING CONDITIONS
Works in a typical acute health care setting with adult and geriatric patients (unless assigned to the Nurseries and to Pediatrics), and families experiencing a wide range of medical and/or surgical problems. Requires standing and walking for extensive periods of time. Requires corrected vision and hearing to normal range. Requires working under stressful conditions. Requires exposure to communicable diseases or body fluids. Requires ability to lift and turn patients. Requires prolonged periods of time spent on the telephone. This is not a patient facing position.
Full-Time Benefits
* 403(b) Matching (Retirement)
* Dental insurance
* Employee assistance program (EAP)
* Employee wellness program
* Employer paid Life and AD&D insurance
* Employer paid Short and Long-Term Disability
* Flexible Spending Accounts
* ICHRA for health insurance
* Paid Annual Leave (Time off)
* Vision insurance