RN Clinical Documentation

JOB SUMMARY

Improves the overall quality and completeness of clinical documentation through the application of evidence-based knowledge, analysis, in-depth review, interpretation, identification of opportunities, communication and consistent follow-up and evaluation of concurrent and retrospective (as required) medical record documentation. Interacts primarily with, but not limited to, physicians, nursing staff, other patient caregivers and health information coding staff to capture appropriate reimbursement and clinical severity for the level of service rendered to all patients, with a focus on DRG-based payers. Facilitates timely, accurate and complete documentation of clinical information used for measuring and reporting physician and hospital outcomes in compliance with regulatory standards. Educates all members of the patient care team on issues relating to clinical documentation. Works with Clinical Data Analyst – ICCM to quantify complete and accurate clinical documentation and utilization, focusing on DRG payers. Demonstrates knowledge of DRG payer issues for documentation opportunities, clinical documentation requirements, coding standards as applied to medical record documentation and compliance requirements. Demonstrates working knowledge of APR DRG's and intensity of service criteria. Applies teaching/learning principles in establishing an overall educational program related to effective clinical documentation for, and in collaboration with, physicians and the health care team. Develops and maintains close working relationships with physicians and the departments of coding, nursing, health information management, quality and managed care, as well as ancillary departments responsible for clinical documentation. Position requires self-directed, independent decision-making, analytical teaching and articulate communication skills, both verbal and written. Assumes responsibility and accountability for incorporating the mission, vision, values and critical goals of the organization into job performance. Demonstrates enhanced knowledge of anatomy and pathophysiology to facilitate the increased need for granularity and specificity in the clinical documentation with the transition to new coding systems. Demonstrates the ability to accurately utilize coding guidelines, software and resource material. Provides informal and formal education on required documentation and acts as a resource to physicians and other members of the health care team.

ESSENTIAL FUNCTIONS