[Hiring] Registered Nurse - Clinical Documentation Specialist @Dartmouth Health

Role Description

Facilitates improvement in the overall quality, completeness and accuracy of medical record documentation. Educates members of the patient care team on documentation guidelines.

• Performs ongoing medical record reviews using documentation improvement guidelines.
• Evaluates overall quality and completeness of clinical documentation.
• Conducts follow-up reviews of clinical documentation.
• Initiates and maintains interactions with physicians and mid-level providers on a concurrent basis to address the need for more detailed information in the medical record.
• Ensures the severity of illness and level of services provided are accurately reflected in the medical record.
• Reviews clinical picture of the patient and assigns a working DRG.
• Ensures the working DRG is entered in the appropriate database/IDX system and trends completion of DRG worksheets.
• Establishes and maintains a system to track and analyze outcomes of documentation improvement program.
• Prepares regular outcomes progress reports and presents.
• Facilitates and participates in regular team meetings with the Coding staff.
• Works with inpatient coders to ensure appropriate DRG assignment and that reimbursement reflects the level of services rendered.
• Uses performance improvement methodologies and education strategies to develop formal training and improvement programs for the staff concerning clinical documentation opportunities, coding and reimbursement issues.
• Provides ongoing updates as regulations change.
• Educates Coding team members on clinical (diagnostic and therapeutic) updates on an ongoing basis.
• Utilizes nursing and clinical knowledge to respond to payors concerning clinical denials, as assigned.
• Provides clinical documentation expertise to assist in resolving outpatient issues involving physician documentation.
• Performs other duties as required or assigned.

Qualifications

• Must have the ability to create and maintain strong relationships and confidently discuss clinical diagnoses.
• Excellent verbal and written communication abilities required.
• Demonstrated interpersonal skills, including negotiation, conflict resolution, follow-through and follow-up.
• Must have good organizational skills including project management, with attention to detail and accuracy.
• Must possess the ability to develop and deliver clinical education programs on clinical documentation improvement for the Medical Staff and Hospital Staff.
• Must have the following computer competencies: data entry and analysis, word processing, and presentations.
• Knowledge of DRG prospective payment systems, documentation & coding guidelines and compliance requirements preferred.
• Current knowledge of DRGs and payment regulations preferred.
• Up-to-date clinical knowledge, understand clinical picture of the patient condition and identify opportunities for improved documentation.
• 3 years of applicable experience.

Requirements

• Licensed Registered Nurse with NH eligibility.

Benefits

• Loan repayment up to $20,000.
• Generous tuition reimbursement.
• Very popular "earned time" plan.
• Extensive CEU/Training programs.
• Rigorous, research-focused environment.
• Accredited provider of continuing nursing education by the American Nurses Credentialing Center.