RN Clinical Documentation Specialist
Brandon Regional Hospital - Brandon - Brandon, FL

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Brandon Regional Hospital

has more than a 30-year tradition of expanding medical programs and services to meet the needs of the community.

Today, the hospital is a 407-bed acute care facility offering a number of specialty services including the Heart & Vascular Center, where the latest in cardiovascular surgery and minimally invasive techniques are performed. The hospital was recently named a Blue Cross Blue Shield Blue Distinction Cardiology Center for cardiac care.

In early January of 2009, we opened the Neuroscience Center, as part of our growing Spine Care Center program providing a new level of care for the community featuring treatments for brain and spinal tumors, epilepsy, spinal disorders and more.

More than 60,000 deliveries have occurred at the Women's and Children's Center, one of the largest obstetrical services in Hillsborough County. We feature a Level III Neonatal Intensive Care Unit (NICU).

Other recognitions include being named

One of America's Top 100 Hospitals, five times, and a Top 100 ICU by Solucient, Inc.

and numerous recognitions for clinical excellence. Additional certifications include Joint Commission Primary Stroke Center. CyberKnife Cancer Center at Brandon Regional Hospital will be opening in the early part of 2009 offering a non invasive way to treat cancer and will round out our Oncology program that includes breast care and prostatectomy.

The

Clinical Documentation Specialist

is responsible for the following:
Demonstrates responsibility and accountability in ensuring all admissions and continued stays meet clinical criteria for appropriateness and medical necessity. Assesses discharge planning needs and coordinates the delivery of care to meet these needs.

Develops, initiates, and coordinates individual patient case management plans to ensure appropriate level of care across the continuum. Ensures plan meets patient's clinical, psychological and discharge needs in collaboration with the attending physician and interdisciplinary team.

Evaluates patients educational needs concerning continuum of care and available services and provides information and materials regarding community resources, discharge options, and pre and post treatment options and costs to patient and patient families.

Assesses the health status of assigned patients by collecting and analyzing patient and family data, and expedites and coordinates the delivery of services to facilitate patient's progression through the healthcare system.

Utilizes appropriate clinical documentation to identify opportunities and ensure accuracy and completeness of clinical documentation used for measuring and reporting physician and hospital outcomes.

Performs concurrent hospital-wide medical record reviews facilitating improvement in the quality, completeness and accuracy of medical record documentation to ensure coding compliance, accurate reporting, and improved patient outcomes.

Acts as organizational consultant, and provides education for members of the patient care team, including medical staff, on documentation guidelines on an on-going basis.

Identifies, and facilitates implementation of strategies for sustained work process changes that facilitate complete and accurate clinical documentation.

Utilizes philosophies and practices to support Patient Service Excellence, such as AIDET, rounding with purpose, and discharge calls, etc. to optimize healing environment and patient outcomes. Works collaboratively with others to ensure hospital-wide improvement in meeting quality, core measures, and patient service excellence goals.

Assesses medical records for Continued Stay with respect to medical necessity and conducts thorough follow-up reviews to ensure accurate documentation. Utilizes sound judgment to refer inappropriate admission, unnecessary stay, improper service utilization and quality concern cases to Physician Advisor.

Performs duties in accordance with departmental policies and procedures, objectives, quality assurance programs, safety, environmental and infection control standards. Ensures safety activities and medical center processes are accurately accessed and documented.

Demonstrates knowledge of the occurrence reporting system. Uses system to report potential patient safety issues.

Follows established guidelines for reporting a significant medical error or an unanticipated outcome in the patient's care, which results in patient harm. Uses Performance Improvement Plan to improve patient safety.

Qualifications

Current RN License required.

Bachelors Degree in Nursing or Healthcare related field preferred.

Minimum of three years of clinical experience in acute care setting. Critical Care, Emergency department, or Telemetry nursing preferred.

Experience in Quality, Case Management, Clinical Auditing or Data Abstraction necessary.

Interpersonal Communication skills to motivate and manage an improvement process.

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Creating a culture of commitment and compassion, One Person at at time! Brandon Regional Hospital is committed to providing our patients...