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Creating remarkable health experiences, freeing people to be their best.
RN Clinical Document Specialist
Location
United States
Posted
3 days ago
Salary
$31 - $49 / hour
Seniority
Mid Level
No structured requirement data.
Job Description
RN Clinical Document Specialist
Highmark Health
Role Description Improves the overall quality and completeness of medical documentation; facilitates enhancements to clinical documentation through extensive interaction with physicians, nursing staff, case managers, other patient caregivers, and medical records coding staff to ensure that the appropriate reimbursement is received for the level of service rendered to all inpatients; ensures the accuracy and completeness of clinical information used for measuring and reporting physician and hospital outcomes; educates all members of the patient care team on an ongoing basis. Essential Responsibilities - Facilitate appropriate clinical documentation through concurrent, prospective, and retrospective medical record review (30%) - Facilitate modifications to clinical documentation through extensive interaction with physicians, nurses and ancillary staff based on knowledge of coding and HCC guidelines, documentation strategies, and clinical documentation requirements (25%) - Work collaboratively with coding professionals to assure documentation of diagnoses and comorbidities are a complete reflection of the patient's clinical status and care (10%) - Formulate credible clinical documentation clarifications to improve clinical documentation (10%) - Educates all internal customers on compliant documentation responsibilities, coding, and reimbursement issues, as well as performance improvement methodologies (15%) - Performs other duties as assigned or required (10%) Qualifications - Minimum: - High school/ GED - Bachelor's Degree in Nursing OR Relevant experience and/or education as determined by the company in lieu of bachelor's degree - 5 years in a nursing role - Current State of PA RN licensure OR Current multi-state licensure through the enhanced Nurse Licensure Compact (eNLC) - Preferred: - Experience in Clinical Documentation Integrity (CDI) - Experience in Coding - Knowledge of ICD 10 and HCC coding guidelines - Knowledge of Electronic Medical Record (Epic) - Knowledge of Encoder (3M 360 Encompass) - Excellent communication skills - Critical thinking skills - Certified Coding Specialist (CCS) - Certified Outpatient Clinical Documentation Improvement Specialist (CCDS-O) - Certified Clinical Documentation Improvement Specialist (CCDS) - Certified Clinical Documentation Improvement Professional (CDIP) Company Description
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