Senior Medical Writer, Redaction
Syneos Health
RN Clinical Documentation Informaticist
Northern Arizona Healthcare
full-time
Posted on:
Location Type: Remote
Location: Remote • Alabama, Arizona, Florida, Idaho, Kansas, Missouri, Montana, North Carolina, Ohio, Oklahoma, Pennsylvania, South Carolina, Tennessee, Texas, Virginia • 🇺🇸 United States
Visit company websiteJob Level
Mid-LevelSenior
About the role
- Demonstrates an understanding of complications, co-morbidities, severity of illness, risk of mortality, case mix, secondary diagnoses, impact of procedures on DRG and is able to impart this knowledge to physicians and other health team members.
- Demonstrates and utilizes the guidelines of care and practice via the nursing process and in accordance with Arizona State Board of Nursing Laws and Regulations being able to perform at a fully competent level.
- Maintains a review rate of 80% on assigned cases and query rate of 15% on assigned cases, or as determined by clinical performance need. Performs audits of documentation to ensure consistency and that standards are met.
- Communicates with physicians face-to-face or through clinical documentation inquiry forms to clarify information, obtain needed documentation, present opportunities and educate for appropriate MS-DRG based on severity of illness.
- Confers with HIM coders to ensure appropriate MS-DRG assignment and completeness of supporting documentation.
- Confers with Physician Advisor as needed.
- Conducts concurrent and retrospective review of each assigned patient in the time frame and frequency as required.
- Identifies and records the most appropriate principal diagnosis, secondary diagnosis, complications/co-morbidities and procedures to reflect the severity of illness and risk of mortality.
- Identifies opportunities for improvement in documentation processes.
- Maintains accurate data in the tracking database to identify trends and issues, developing action plans to achieve team goals.
- Responsible for reporting any safety-related incident in a timely fashion through the Midas/RDE tool; attends all safety-related training programs; performs work in a safe manner; monitors work environment for possible safety issues and ensures others are also performing work in a safe manner.
- Stays current and complies with state and federal regulations/statutes and company policies that impact the employee's area of responsibility.
- If required for the position, ensures all certifications and/or licenses are up-to-date and valid prior to expiration dates.
- Completes all company mandatory modules and required job-specific training in the specified time frame.
Requirements
- Associates RN, RHIA/RHIT, or Bachelor's Degree with experience/certification in Coding/CDI- Required
- BSN- Preferred
- CCDS- Required after 2 years of hire date
- Current RN License (does not have to be AZ)- Required
- 3-5 years clinical documentation specialist, coding, or UR experience- Preferred
- Supervisory, education, or leadership experience- Preferred
- Computers and other electronic devices are utilized across the organization and throughout each department. Colleagues must have an understanding of computers, and competence in using computers and basic software programs.
Benefits
- Telecommute
- Days schedule
Applicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard skills
clinical documentationcodingMS-DRG assignmentauditingdata trackingdocumentation improvementrisk of mortality assessmentseverity of illness evaluationcase mix analysisco-morbidities identification
Soft skills
communicationcollaborationeducationleadershipproblem-solvingattention to detailorganizational skillsinterpersonal skillscritical thinkingtime management
Certifications
RN LicenseRHIARHITCCDS
