Job detail

RN, OP Clinical Doc Improvement Specialist, FT

Unity Health

#Registered Nurse #Healthcare Team #State Regulations #Insurance Authorization #Federal Regulations #CMS #Medical Record #Severity of Illness #Case Mix

Quick overview

The Clinical Documentation Improvement Specialist facilitates modifications to medical records through concurrent interaction with physicians to ensure accurate clinical severity and billing levels. They evaluate documentation, lab results, and treatment plans to support the level of service rendered.

Requirements summary

Candidates must hold a current Arkansas registered nurse license, with a BSN preferred or equivalent coding certification and ten years of inpatient coding experience. The role requires at least two years of recent inpatient experience and proficiency in clinical documentation policies and federal regulations.

bachelor degreeprofessional certificateOrganizationPlanningVerbal communicationSelf-motivationWritten communicationClinical expertiseData analysisWord processingPhysician communicationPresentation programsCMS regulationsInpatient codingClinical documentation improvementMedical record evaluationSpreadsheet analysisInternet search

Job description

1. Education / Credentials

Current Arkansas licensure as a registered nurse; Bachelor of Science ( BSN ) preferred or CCS/RHIA/RHIT with ten years of inpatient coding experience.

2. Training and Experience

Advanced clinical expertise and extensive knowledge of complex disease processes with a broad clinical experience in an inpatient setting

3. Job Knowledge: Clinical expert with at least 2 years recent inpatient experience

Excellent verbal and written communication skills

Proficiency in organization and planning

Proficiency in computer usage including database and spreadsheet analysis, presentation programs, word processing and internet search

Ability and willingness to seek out and accept change

Demonstrates adaptability and self-motivation by staying abreast of CMS rules and regulations and incorporating those changes into daily practice

Knowledge of federal, state and private payer regulations

4. Safety Sensitive: NO

In the interest of protecting the health and safety of all patients, associates, and guests, Unity Health has classified some positions as “safety sensitive.” A “safety sensitive” position is any job position in which impaired performance could result in harm to the health and/or safety of self or others. Any associate that is actively engaged in the use of medical marijuana, even if in possession of a valid medical marijuana card, will be excluded from employment in a “safety sensitive” position.

Description

The Outpatient Clinical Documentation Improvement Specialist facilitates modifications to clinical documentation through concurrent interaction with physicians and other members of the health care team to support that appropriate clinical severity is captured for the level of service rendered to all inpatients.

The CDIS will

Provide daily clinical evaluation of the medical record including physician and clinical documentation, lab results, diagnostic information and treatment plans, authorization of insurance for procedure performed and notification to Insurance if this changes
Be responsible for the day-to-day evaluation of documentation by the Medical Staff and healthcare team in accordance with the hospital’s designated clinical documentation policies and procedures to support the procedure performed