What are the responsibilities and job description for the Registered Nurse-Clinical Documentation Improvement Specialist-Days position at BHST?
We are looking to add top talent to our Baptist Hospitals of Southeast Texas team.
Join us in performing Sacred Work!
Competitive benefits are offered including:
Matched Retirement Plan
Paid Time Off
Comprehensive Benefit Plan – Medical, Dental, Vision and Much More!
Bonus Potential
Summary/Objective
Under the direct supervision of the Director of Case Management, the Clinical Documentation Improvement Specialist is responsible for reviewing targeted medical records and collaborate with physicians to ensure documentation accurately reflects and supports the patient’s acuity, SOI/ROM scores, use of resources, and quality of care provided.
Essential Job Duties
Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. This position may be performed via Telecommuting (refer to Human Resources Policy Number: HRF.03.01.0051)
1. Prioritize Concurrent & Retrospect daily review list in accordance with established productivity expectations. 2. Complete reviews of the medical records to establish a working DRG – generates physician query for missing/non-specific/conflicting documentation based on supporting clinical indicators or queries for LOS / SOI / ROM. Utilizes good written and verbal communication skills.
3. Engage and educate physicians and key healthcare providers regarding the need for accurate and complete documentation in the medical record. Develops and maintains a positive relationship with providers and ensures timely response to open queries.
4. Collaborates with members of the healthcare team regarding physician documentation and query response needs. 5. Perform 100% reconciliation of all reviews. Clarifies final DRG discrepancies with Coding Director and CDI supervisor. Reviews ENJOIN’s recommendations daily for educational opportunities.
6. Participate in the analysis and trending of statistical data to identify opportunities for documentation improvement. Report patterns of inadequate physician documentation and responses to CDI supervisor and/or Physician Advisor for appropriate follow up.
Required Education and Experience
Associates of Science degree in Nursing required.
Three (3) years Staff Nurse experience in an acute inpatient setting is required. Experience in Critical Care and adult Med/Surge is required. .
Required License/Certifications
Current unrestricted licensure in Texas as a Registered Nurse or a recognized compact state license. Proof of BLS certification within 30 Days.