Job Description

Job Description

Rutherford Regional Health System

Summary:

Facilitates improvement in the overall quality, completeness, and accuracy of clinical documentation. Through concurrent interaction with physicians, case managers, coders and other health care team members, the Clinical Documentation Specialist, will strive to ensure comprehensive medical record documentation that reflects the clinical treatment, decisions, and diagnosis for all inpatients. Serving as a resource to all members of the health care team on documentation guidelines, this position will provide guidance and support, as well as assist with education and training related to improving clinical documentation.

Reports to: Director, Health Information Management

Essential Functions:

Conducts daily reviews of inpatient medical records to identify missing, vague, and/or incomplete diagnoses and procedures. Conducts timely follow-up reviews of clinical documentation to ensure that issues discussed and queries left in the medical record have been answered by the provider. Adheres to chart review productivity standards.

Utilizes coding and clinical expertise to identify opportunities and ensure the accuracy and completeness of clinical documentation used for measuring and reporting physician and hospital outcomes.

Queries physicians on specificity of procedures performed and diagnoses based on accepted coding guidelines, clinical expertise and LifePoint Hospitals query policy.

Tracks and trends specific opportunities for CDI process improvement through the utilization of metrics reports.

Prepares and presents educational programs to all internal constituents related to clinical documentation issues and coordinates same with clinical staff, physicians, compliance and coding staff.

Makes regular reports of progress toward goals associated with clinical documentation improvement opportunities and operational improvement plans.

Assumes responsibilities for following compliance guidelines with federal, state, and local regulations within the department.

Participates in data collection to document findings and outcomes to drive quality improvement and improved clinical documentation.

Works closely with case management, quality management, risk management, and medical staff credentialing to provide data related to key clinical indicators and operational metrics.

Ability to establish cooperative working relationship with diverse groups and individuals, medical staff and other health care disciplines and interact with all levels of employees.

Job Requirements

Minimum Education
Associates Degree in Nursing required
Bachelor's Degree in Nursing preferred

Required Skills
Requires critical thinking skills, decisive judgment and the ability to work with minimal supervision. Must be able to work in a stressful environment and take appropriate action.

Required Skills
Licenses:
Current RN license to practice in NC (NC licensure or multi-state (compact) license).

Certification:
RHIA, RHIT required
CCDS or CDIP preferred

Minimum Work Experience
1-3 years of experience working in chart review procedures, typically acquired by work experience of a clinical documentation improvement specialist, utilization review nurse, or inpatient coder.

Required Skills
Prior experience with Microsoft Office Suite preferred
Prior experience with clinical record review preferred
Prior experience with CDI software preferred

LifePoint Health is committed to providing Equal Employment Opportunities for all applicants and employees and complies with all applicable laws prohibiting discrimination against any employee or applicant for employment because of color, race, sex, age, religion, national origin, disability, genetic information, gender identity, sexual orientation, veterans status or any other basis protected by applicable federal, state or local law.