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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.
RN licensed in the state of Arkansas.
. Five (5) years experience in a current clinical setting
Hearing, seeing, speaking, writing, fingering, grasping, reaching, and lifting up to 10 lbs.
Telephone w/ voice mail, Fax machine, pagers, and computer
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)
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.
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.
Conifer - Little Rock, AR
40 Hour Week With Overtime
Tenet Healthcare - 18 months ago