Registered Nurse RN Clinical Documentation Specialist

Primary City/State:
Arizona, Arizona

Department Name:

Work Shift:

Job Category:
Revenue Cycle

Explore and excel. At Banner Health, health care is a team effort. One might be surprised by the number of people who work behind the scenes and play a critical role in ensuring the best care for our patients.

The mission of the Clinical Documentation Improvement Department is to, " Facilitate concise clinical documentation to appropriately reflect patient acuity, risk of mortality, and resource utilization in order to properly reflect patient care given and optimize organizational goals." This mission also supports the accurate translation of diagnoses into ICD-10 codes for patient billing and capture of quality metrics.

As a successful Clinical Documentation Improvement Specialist will need to have at a minimum 2-4 years of hospital acute-care or relevant clinical experience. Time in OR, ED or ICU may strengthen a candidates profile. Level of education may be either registered nurse with active licensure in state worked or graduate of foreign medical school with Doctor of medicine degree.

This is a fully remote position and available if you live in the following states only: AK, AL, AR, AZ, CA, CO, FL, GA, IA, ID, IN, KS, KY, MI, MN, MO, MS, NC, ND, NE, NM, NV, NY, OH, OK, OR, PA, SC, TN, TX, UT, VA, WA, WI & WY. This position is fully remote with travel less than 15% of the time to either a Banner corporate or hospital site. With this remote work, candidates must be self-motivated, possess moderate to strong tech skills and be able to meet daily and weekly productivity metrics. Business hours are Monday-Friday, 8 hour shifts with no weekends or holidays. Apply today!

POSITION SUMMARY
This position is responsible for reviewing content of the medical record and assisting in the clarification of any documentation ambiguities noted. This position is a member of the clinical team and acts as a consultant/subject matter expert to facility staff and Providers related to medical record clinical documentation requirement to ensure the overall completeness, compliance and specificity of Provider documentation exists. This position is responsible for identifying and capturing additional revenue opportunities and will also be the documentation liaison for the facility between acute care coding and Providers.

CORE FUNCTIONS
1. Provides subject matter expertise related to DRG, clinical documentation opportunities and requirements. Serves as an essential member of the clinical team, emphasizing their role in reviewing content of the medical record, assisting in the clarification of documentation ambiguities. Serves as the liaison between acute care coding and Providers to explain, educate and assist in the needed documentation requirements to accurate conversion from the "clinical language" to the needed "coding language" in order to capture revenue.

2. Conducts accurate and timely concurrent record reviews, recognizing opportunities for documentation improvement through specialized training and software. Utilizes available resources to formulate clinically credible "documentation clarification questions" for members of the clinical team aimed at improving the accuracy of the documentation process which is followed by effective and appropriate communication with Providers and timely follow up on all cases.

3. Ensures data integrity of the clinical documentation database through compliant, accurate and appropriate entries, which include but is not limited to, accurate input of case data, correct assignment of documentation clarification types and Provider responses, and ensuring precise case reconciliation with correct DRG shifts recorded.

4. Ensures the accuracy and completeness of clinical information used for measuring and reporting Provider and facility outcomes (coding assignments, HAC, quality of care, facility and system initiatives) while facilitating HIMS dept compliance of time requirements for coding and billing revenue cycle.

5. Educates customers through presentations and/or reports for clinicians and facility management on clinical documentation opportunities, acute care coding and reimbursement issues, as well as performance improvement methodologies.

6. Serves as member of facility task force meetings, and as requested attends facility steering committee meetings and/or other facility meetings.

7. This position works independently in a remote work model and has multi-facility/entity responsibility, with no direct budgetary oversight. This position is a member of the clinical team ensuring accuracy and compliance with acute care coding assignments, POA status, HAC, quality of care, supports specific Hospital and System initiatives, and aids HIMS Dept in meeting their time requirement of the coding and billing revenue cycle. Extensive interaction with Providers, HIMS professionals, nursing and other ancillary staff. Internal Interactions: All levels of nursing management and staff, medical staff, Providers and all other members of the interdisciplinary health care team. External Interactions: Physicians and their office staff.

MINIMUM QUALIFICATIONS

Must possess a strong knowledge of clinical care as normally obtained through the completion of a bachelor's degree in nursing.

Requires Registered Nurse (R.N.) license in state of residence.

Requires two to four years of recent acute care experience either in a Hospital or Surgical setting. Must have the ability to interface with multiple software applications, work independently, possess demonstrated critical thinking skills, problem-solving abilities, communication and time management skills. Must demonstrate ability to work effectively in an interdisciplinary team format.

PREFERRED QUALIFICATIONS

Experience with acute clinical documentation programs or coding. Certified Clinical Documentation Specialist, Certified Coding Specialist credential.

Additional related education and/or experience preferred.

EEO Statement:

EEO/Female/Minority/Disability/Veterans

Our organization supports a drug-free work environment.

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