Clinical Documentation Registered Nurse, RN
Tenet Healthcare
full-time
Posted on:
Location Type: Hybrid
Location: Birmingham • Alabama • 🇺🇸 United States
Visit company websiteJob Level
Mid-LevelSenior
About the role
- Responsible for reviewing medical records to facilitate and obtain appropriate physician documentation for any clinical conditions or procedures to support the appropriate severity of illness, expected risk of mortality, and complexity of care of the patient, by improving the quality of the physicians’ clinical documentation
- Educates members of the patient care team regarding documentation guidelines, including the following: attending physicians, allied health practitioners, nursing, and case management
- Completes initial medical records reviews of patient records within 24-48 hours of admission for a specified patient population to: (a) evaluate documentation to assign the principal diagnosis, pertinent secondary diagnoses, and procedures for accurate MS-DRG assignment, risk of mortality and severity of illness; and (b) record in business partner designated CDI tool and/or host medical record system
- Conducts follow-up reviews of patients every 24-48 hours or as needed up through discharge to support assigned working MS-DRG assignment upon patient discharge, as necessary
- Formulate physician queries regarding missing, unclear, or conflicting health record documentation by requesting and obtaining additional documentation within the health record, as necessary
- Collaborates with providers, case managers, nursing staff and other ancillary staff regarding documentation and to resolve physician queries prior to discharge
- Communicates/Completes Clinical Documentation Integrity (CDI) activities and coding issues (lacking documentation, physician queries, etc.) for appropriate follow-up, provider education and DRG Miss-Match reconciliation
- Assists with Provider education, rounding and communication regarding open queries for resolution
- Stays current with AHA Official Coding and Reporting Guidelines, CMS and other agency directives for ICD10-CM and PCS coding
- Attends CDI Boot camp, CDI/coding trainings annually and quarterly for inpatient coding
- Attends monthly education lecture series (MELS) and all CDI/coding assigned learn share modules as well as any additional required CDI education
- Assists in training department staff new to CDI
- Performs other duties as assigned
Requirements
- Preferred: Acute Care nursing and/or Provider relevant experience
- Zero (0) to two (2) years CDI experience
- Two (2) plus years’ nursing experience – Medical/Surgical/Intensive Care and/or Case/Utilization Review
- Two (2) plus years’ Provider experience – Medical/Surgical/Intensive Care and/or Case/Utilization Review
- Graduate from a Nursing program, BSN, or graduate program; OR
- Graduate from Medical Doctor and/or Foreign Medical Doctor Program
- Active state Registered Nurse license; OR
- Graduate MD and/or FMD license
- Preferred: CDIP or CCDS
Benefits
- Conifer requires its candidates, as applicable and as permitted by law, to obtain and provide confirmation of all required vaccinations and screenings prior to the start of employment. This may include, but is not limited to, the COVID-19 vaccination, influenza vaccination, and/or any future required vaccines and screenings.
Applicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard skills
clinical documentationmedical records reviewICD10-CM codingPCS codingMS-DRG assignmentphysician queriesdocumentation guidelinesCDI toolrisk of mortality assessmentseverity of illness evaluation
Soft skills
communicationcollaborationeducationproblem-solvinginterpersonal skillsorganizational skillsleadershiptrainingteamworkcritical thinking
Certifications
CDIPCCDSRegistered Nurse licenseBSNMedical DoctorForeign Medical Doctor