What are the responsibilities and job description for the Clinical Documentation Special (FT) position at Columbus Regional Healthcare System?
At Columbus Regional Healthcare System we offer professional growth and advancement for every employee.
Job Description: Facilitates the improvement of clinical documentation and ensures accuracy of the level of clinical services and patient severity by conducting clinically based concurrent reviews of inpatient medical records to evaluate the clinical documentation of acute care services. Works closely with the Medical Staff to facilitate appropriate physician documentation of patient care. Responsible for reporting quality of care outcomes and in obtaining accurate and compliant reimbursement for acute care services. Provides interdisciplinary education about regulatory and reimbursement changes. Improves the physicians’ medical record documentation by addressing incomplete documentation through direct interaction with physicians. Indirectly assures case mix index, Diagnostic Review Group (DRG) assignment and severity/mortality profiles are accurate by reviewing up to date reports and working closely with the Case Managers and Coders. Develops concurrent education programs for physicians and other clinical staff to improve adherence to proper documentation.
Qualifications:
- BS in Nursing or Associate Degree in Nursing with documented experience in the fields of quality management, case management, utilization review with strong coding skills will be considered in lieu of BS.
- Current RN license from NC or compact state.
Preferred: BS in Nursing
Experience: 5 years acute care nursing experience. Knowledge of ICD-10-CM coding guidelines. Knowledge of regulatory guidelines and standards. Prior case management experience is desirable.
Perks Benefits:
- Competitive Pay Rates
- Company Swag
- Comprehensive Benefit Package
- Tuition Reimbursement
- Matching Retirement Plan
- Sign on Bonus (select positions)