Responsible for facilitating the improvement in the overall quality and completeness of medical record documentation. Obtain appropriate clinical documentation through extensive interaction with physicians, nursing staff, other patient caregivers, and the Medical Record coding staff to ensure that appropriate reimbursement is received for the level of services rendered to patients and the clinical information utilized in profiling and reporting outcomes is complete and accurate. On an ongoing basis educates all members of the patient care team on documentation guidelines.
Facilitates appropriateness of clinical documentation to ensure that documentation reflects the level of service rendered to all patients with a DRG based payor.
Demonstrates knowledge of DRG payor issues, optimization strategies, clinical documentation requirements and referral policies and procedures.
Improves the overall quality and completeness of clinical documentation by performing admission/continued stay reviews using clinical documentation Integrity (CDI) guidelines.
Ensures the accuracy and completeness of clinical information used for measuring and reporting physician and Huntsville Hospital outcomes.
Assisting in screening process, making referrals, interacting with case managers and clinical nurse specialists to ensure continuity of patient care.
Process discharges by updating the DRG worksheet to reflect any changes in status, procedures/treatments and conferring with physician to finalize diagnosis.
Educates all internal customers on clinical documentation opportunities, coding and reimbursement issues, as well as performance improvement methodologies.
Conducts follow-up reviews of clinical documentation to ensure points of clarification have been entered into the patient's medical record.
Reviews clinical issues with coding staff to assign a working DRG.
Tracks response to CDI and trends completion of DRG worksheets.
Serves as a member of the CDI Work Group, assists with special projects as needed and performs related duties as assigned.
Maintains positive open communication with physicians, interdisciplinary team members, and the department's director.
As appropriate, participates in QI/PI data collection, evaluation and recommendations for improvement.
Refers quality issues to the department's director.
Demonstrates knowledge of the principles of growth and development over the life span of the patient to include pediatrics, adolescents, adults, and geriatrics
Education Required
Graduate of an Accredited School of Nursing required.
Education Preferred
License, Certification and/or Registration
Current Alabama Nursing License.
Experience
Prefer at least 5 to 7 years of experience in an acute care hospital setting.