Department:10169 Enterprise Corporate - Clinical Documentation Improvement
Status:Full time
Benefits Eligible:Yes
Hours Per Week:40
Schedule Details/Additional Information:Full-time, dayshift Monday - Friday 8:00am- 5:00 pm and will be a Hybrid role with onsite days in Cleveland, NC.
Pay Range:$38.20 - $57.30
Major Responsibilities:- Reviews selected populations of inpatient medical records to identify the principal and/or secondary diagnoses. Appropriately assigns the MS-DRG that most accurately reflects the severity of illness of the patient based upon the clinical evidence documented at the time of the record review.
- Demonstrates knowledge and understanding of severity based DRG systems; All Patient Refined and Medicare Severity (AP-DRG) and Medical Severity Diagnostic Related Group System (MS-DRG).
- Demonstrates the ability to utilize the licensed software tool to perform and record daily medical record reviews.
- Interacts with the physician and/or other designated members of the healthcare team to ensure that vague or incomplete documentation is clarified within the medical record in a timely manner.
- Works with other departments such as coding, corporate compliance, quality, and finance to support Corporate Goals.
- Participates in the ongoing education of physicians, nurse practitioners, physician assistants and other healthcare team members to identify medical record documentation improvement opportunities employing conflict resolution skills as necessary.
- Utilizes critical thinking skills based upon extensive knowledge of disease processes and clinical outcomes to identify the need for further clarification of physician documentation within the medical record.
- Ensures that all written requests to physicians for additional documentation support Corporate Compliance policies.
Licensure, Registration, and/or Certification Required:- Registered Nurse applicable state Licensure required.
Education Required:- Bachelor's Degree Required.
Experience Required:- Appropriate professional certification required within 3 years of hire date per department protocol.
- 5 years of related nursing experience preferred. Clinical experience within the assigned population.
- Extensive knowledge of disease processes and clinical outcomes.
- Case Management experience or background helpful.
Preferred Experienced:- Strong financial and analytical skills.
- Word, Outlook, Excel
Physical RequirementsWorks in an office type setting, extensive walking throughout the facility. Prolonged periods of sitting reviewing medical records and documentation. Repetitive wrist motion and occasional lifting of 10-20 pounds. Intact sight and hearing with or without assistive devices are required. Ability to speak English fluently and write in understandable terms.
Our Commitment to You:Advocate Health offers a comprehensive suite of Total Rewards: benefits and well-being programs, competitive compensation, generous retirement offerings, programs that invest in your career development and so much more - so you can live fully at and away from work, including:
Compensation- Base compensation listed within the listed pay range based on factors such as qualifications, skills, relevant experience, and/or training
- Premium pay such as shift, on call, and more based on a teammate's job
- Incentive pay for select positions
- Opportunity for annual increases based on performance
Benefits and more- Paid Time Off programs
- Health and welfare benefits such as medical, dental, vision, life, and Short- and Long-Term Disability
- Flexible Spending Accounts for eligible health care and dependent care expenses
- Family benefits such as adoption assistance and paid parental leave
- Defined contribution retirement plans with employer match and other financial wellness programs
- Educational Assistance Program
Note: Eligibility for programs listed above may depend on your FTE or status (e.g., full-time, part-time, per diem, temporary, etc.); please ask a Recruiter for more information during an interview.
