Clinical Documentation Registered Nurse II, ClinicalDocumentation Integrity - Full Time
Company: Christus Health
Location: Beaumont
Posted on: April 25, 2024
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Job Description:
Description Summary: This position is responsible for
facilitating improvement in the overall quality and completeness of
the medical record documentation. The clinical documentation RN
will provide support and expertise through comprehensive assessment
and review of inpatient medical records. The clinical documentation
RN will facilitate accurate DRG assignment and obtain appropriate
documentation through extensive interaction with physicians,
patient caregivers and health information management coding staff
to ensure that reimbursement is received for the level of services
rendered to the patients. Analyzes clinical status of patient,
current treatment plan and past medical history and identifies
potential gaps in physician documentation Communicates with
attending physician either verbally or through written methodology
to validate observations and suggest additional and/or more
specific documentation Maintains positive open communication with
physicians, nursing and all other disciplines involved in the care
of the patient Works closely with HIM Coding staff to assure
documentation of discharge diagnosis and any co-existing
co-morbidities are a complete reflection of the patient's clinical
status and care Maintains an electronic DRG worksheet to assist
coders on identifying all documented diagnosis and procedures
Updates DRG worksheet to reflect any changes inpatient
status/procedure/treatment and confers with the physician to
finalize diagnosis Consistently meets established productivity
targets for record review Designs and implements in collaboration
with physician leadership specific tools to support medical record
physician documentation Develops and implements plans for both
formal and informal education of physician, nursing, and other
clinical staff on clinical documentation opportunities, coding and
reimbursement as well as performance improvement methodologies
Assists in collection and organization of data for analysis by
appropriate medical and hospital committees Identifies strategies
for sustained work process changes that facilitate complete,
accurate clinical documentation Demonstrates competence to perform
assigned responsibilities is a manner that meets the
population-specific and developmental needs of the members served
by the department Appropriately adapts assigned assessment,
treatment, and/or service methods to accommodate the unique
physical, psychosocial, cultural, age-specific and other
developmental needs of each member served Takes personal
responsibility to ensure compliance with all policies, procedures
and standards as promulgated by state and federal agencies, the
hospital, and other regulatory entities Performs all duties in a
manner that protects the confidentiality of patients and does not
solicit or disclose any confidential information unless it is
necessary in the performance of assigned job duties Performs other
duties as assigned Requirements: Associate's Degree in Nursing RN
License in state of employment or compact Work Type: Full Time This
position is not remote. Required to sit on-site at St. Elizabeth
hospital in Beaumont, Tx. EEO is the law - click below for more
information: -
https://www.eeoc.gov/sites/default/files/2023-06/22-088_EEOC_KnowYourRights6.12ScreenRdr.pdf
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website or need assistance completing the application process,
please contact us at (844) 257-6925.
Keywords: Christus Health, Beaumont , Clinical Documentation Registered Nurse II, ClinicalDocumentation Integrity - Full Time, Healthcare , Beaumont, Texas
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