RN-Clinical Documentation Specialist I, Little Rock AR Full time
Conifer - Little Rock, AR

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1305001563

Tenet, through its subsidiaries, owns and operates acute care hospitals and numerous related health care services. Our mission is to be recognized for our commitment to our people and partners who provide quality, innovative care to the patients we serve in our communities. It's a spirit you can experience first-hand and it's a philosophy that can enhance your own approach to health care and your career goals.

Description

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At Conifer Health Solutions, we offer the strength and stability of Tenet Healthcare, a Fortune 500 company, with the ingenuity and energy of a healthcare independent. We are a healthcare solutions company born from the healthcare industry. We take care of hospital business, so hospitals can focus on caring for patients. Ready to be part of our solutions? Welcome to a company that gives you the resources and incentives to redefine healthcare services, with the benefits and leadership to take your career to the next step!

JOB SUMMARY:
Responsible for the improvement in the overall quality, completeness and accuracy of all clinical record documentation. Facilitates modifications to clinical documentation through extensive interaction with physicians, nursing staff, other patient caregivers, and health information management coding staff to ensure that clinical documentation reflects the level of service rendered to patients is complete and accurate. Ensures the accuracy and completeness of clinical information used for measuring and reporting physician and medical center outcomes. Educates all members of the patient care team on documentation guidelines on an ongoing basis.

Qualifications

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Education:
RN licensed in the state of Arkansas.

Experience:
. Five (5) years experience in a current clinical setting

Physical Requirements:
Hearing, seeing, speaking, writing, fingering, grasping, reaching, and lifting up to 10 lbs.

Skills:
Telephone w/ voice mail, Fax machine, pagers, and computer

PRIMARY CUSTOMERS:
REPORTING RELATIONSHIPS: Physicians, Nursing Staff, Patient Caregivers, Medical Records, Insurance Verification, and Business Office

Incumbent has access to restricted or confidential patient or other highly sensitive business information and must comply with the terms of SVHS/CHI Policies as they apply to their job role.

AGE GROUPS: ___ Neonate/infant (Birth - 1 mo) ___ Infant (1mo-1yr) ___ Toddler (1yr-3 yrs) ___ Preschool (3 yrs-6yrs) ___ School Age (6 yrs-13yrs) ___ Adolescent (13yrs-18 yrs) __ Adult (18 yrs-64 yrs) __ Older Adult (65+yrs)

ESSENTIAL FUNCTIONS:
1. COMMUNICATION

Reviews clinical issues with the coding staff to assign a working DRG and uses the computer system as necessary.

Maintains positive open communication with physicians, interdisciplinary care team members, and Department Director.

Demonstrates discretion when dealing with sensitive issues involving patients, families and physicians to maintain confidentiality of patient and hospital records.

Retrieves voice mail and/or answers pages within 30 minutes while on duty.

2. DOCUMENTATION

Facilitates modifications to clinical documentation to ensure that appropriate reimbursement for the level of service rendered to all patients.

Documents & analyzes data and reports instances of inappropriate patient care, discharge delays, etc. to Director.

3. COMPLIANT CLINICAL DOCUMENTATION

Facilitates appropriate clinical documentation to ensure the level of services and acuity of care are accurately reflected in the medical record.

Updates DRG worksheet to reflect any changes in patient status, procedures / treatments, and conferring with physician to finalize diagnoses and documentation of quality measures.

Conducts follow-up reviews of clinical documentation to ensure issues discussed and clarified with the physician have been recorded in the patient's chart.

Assists in the medical screening process by documenting appropriateness of patient admission, working DRG & LOS information on worksheet and computer system as appropriate.

4. PRODUCTIVITY / QUALITY

Demonstrates clinical knowledge skills / abilities for the patient population served.

Improves overall quality and completeness of clinical documentation by performing admission / continued stay reviews using Compliant Documentation Program Management.

5. PERFORMANCE IMPROVEMENT / PROFESSIONAL DEVELOPMENT

Stays current with and conducts ongoing clinical documentation management program education for new staff, including new clinical documentation specialists, physicians, nursing staff and allied health professionals.

Tracks program compliance.

Educates all internal customers on compliant documentation opportunities, coding and reimbursement issues as well as performance improvement methodologies.

Attends and participates in weekly educational conferences.

Participates in concurrent performance improvement activities and ongoing medical record review activities.

Attends staff meetings except when excused by supervisor.

Participates in the orientation of new employees.

Demonstrates awareness of fiscal responsibility and impact of actions of the department and hospital budget.

Knowledge of all hospital wide emergency procedures.

Participates in QI/PI data collection, evaluation, and recommendations for improvement.

Completes yearly competencies to include: fire/safety, OSHA, abuse/neglect, and patient safety goals.

6. CUSTOMER SERVICE / SATISFACTION

Demonstrates service excellence behaviors routinely in encounters with all customers, i.e. coworkers, patients, visitors, physicians, etc.

Nonverbal communication conveys a sincere, courteous, and helpful attitude.

Anticipates and responds to the needs of all customers.

Demonstrates flexibility and cooperation in working with others.

Maintains a positive attitude.

Maintains confidentiality per St. Vincent Health System policy.

7. MAY BE RQUIRED TO TRAVEL BETWEEN ST. VINCENT CAMPUSES

May perform other duties as required.

Job

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Nursing

Primary Location

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AR-Little Rock

Hospital/Facility

:

Conifer - Little Rock, AR

Job Type*

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Full-time

Shift Type*

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40 Hour Week With Overtime

Tenet Healthcare - 15 months ago - save job - block
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