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ICU Clinical Documentation Registered Nurse, RN
Tenet HealthcareReviewing medical records and facilitating physician documentation for ICU patients. Educating healthcare teams on documentation guidelines while ensuring compliance with coding standards.
About the role
Key responsibilities & impact- 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.
- 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.
Requirements
What you’ll need- 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
Benefits
Comp & perks- 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.
ATS Keywords
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Hard Skills & Tools
Clinical Documentation Integrity (CDI)Medical record reviewMS-DRG assignmentPrincipal diagnosis assignmentSecondary diagnoses assignmentRisk of mortality assessmentSeverity of illness assessmentPhysician queries formulationDocumentation guidelines educationCase management
Soft Skills
CommunicationEducationInterpersonal skillsOrganizational skillsAttention to detail
Certifications
BSNNursing program graduateMedical DoctorForeign Medical Doctor