Clinical Documentation Nurse - Health information Management

York, PA | Professional | Tracking Code: D57636-2

Position Summary:

General Summary:

 


Under the general supervision of the Manager-Clinical Documentation Improvement, reviews medical record documentation to facilitate the accurate representation of the severity of illness, patient acuity and risk of mortality for a specified patient population. Obtains appropriate clinical documentation through extensive interaction with physicians, healthcare providers and Health Information Management (HIM) professionals. Actively participate in meetings and education of staff related to Clinical Documentation Improvement (CDI).

 


Duties and Responsibilities:

 



1 Facilitates modifications to clinical documentation to ensure that appropriate reimbursement is received for the level of service rendered to all patients by completing accurate and timely record reviews.

2 Improves the overall quality and completeness of clinical documentation by performing admission and continued stay reviews.

3 Demonstrates knowledge of Diagnosis Related Group (DRG) payer issues, documentation opportunities, and clinical documentation requirements.

4 Demonstrates knowledge of Medicare, general understanding of hospital based quality initiatives, and regulatory environment.

5 Ensures the accuracy and completeness of clinical information used for measuring and reporting physician and hospital outcomes.

6 Completes timely follow up on all cases, especially those with clinical documentation clarifications and ensures points of clarification have been recorded in the patients’ medical record.

7 Formulates ethical and clinically credible documentation clarifications.

8 Processes discharges by updating the CDI software to reflect any changes in status, procedures and treatments, and confers with clinicians to finalize diagnoses.

9 Accurately inputs data into the CDI software.

10 Effectively and appropriately communicates with physicians and healthcare providers.

11 Reviews clinical issues with coding staff to assign a working DRG and reconcile final DRG.

12 Serves as a member of the CDI Task Force.

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

14 Prepares educational materials for presentation at meetings, physician grand rounds, interdisciplinary rounds, physician staff meetings, and participates in new provider orientations.



Required Skills

Bachelor’s Degree

Registration and current RN license in PA

 

Required Experience

 

5 years recent acute care with ICU experience;

Case management preferred


Quality of Life

WellSpan Health is an integrated health system that serves the communities of central Pennsylvania and northern Maryland. The organization is comprised of a multispecialty medical group of more than 1,500 physicians and advanced practice clinicians, a regional behavioral health organization, a home care organization, eight respected hospitals, more than 19,000 employees, and 170 patient care locations. WellSpan is a charitable, mission-driven organization, committed to exceptional care for all, lifelong wellness and healthy communities. We are committed to transforming the health of the communities we serve and to educating the next generation of clinicians, staff and leaders.

Quality of Life
Quality of Life

Founded in 1741, the city of York is considered by many as the first capital of the United States. The Articles of Confederation were signed by the Second Continental Congress here in 1777. Its beautifully restored historic district is an architectural treasure. While York retains its farming and manufacturing heritage, at its heart York is a thriving cultural community that has attracted creative talent and innovative entrepreneurial investors from across the nation.

Life in York County offers affordable housing, options for higher education, a thriving arts and cultural community, historical attractions, parks and recreational resources, semi-professional baseball team, fine dining and more — within an easy drive of major East Coast cities.

York County residents can find local employment in healthcare, manufacturing, technology, agricultural and service sectors. (Patient population: 445,000)

Equal Opportunity Employment

WellSpan Health is an equal opportunity employer. Employment selection and related decisions are made without regard to sex, race, age, disability, religion, national origin, color or any other protected class. WellSpan Health does, however, have a tobacco-free/nicotine-free hiring policy.

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