OverviewThis position is responsible for improving the overall quality and completeness of clinical documentation by communicating with and providing education to physicians, case managers, coders and other health team members to facilitate comprehensive medical record documentation that reflects clinical treatment, decisions, and diagnoses for patients. This position may be required to access and administer medications within their scope of practice and according to state law.
ResponsibilitiesEssential Functions- Ensures documentation meets quality standards and an accurate reflection of the patient's status is entered in the medical record.
- Provides education to staff and physicians on the importance of the Clinical Documentation Improvement Program (CDIP).
- Facilitates modifications to clinical documentation through extensive concurrent interactions with physicians, nursing staff and coding to support that appropriate reimbursement and clinical severity is captured.
- Supports timely, accurate and complete documentation of clinical information used for measuring and reporting physician and hospital outcomes.
- Assists the assigned coder with concurrently reviewing the medical records of inpatients and subsequently discusses documentation opportunities with the various physician teams.
- Acts as consultant to coders when additional information or documentation is needed to assign the correct DRG.
- Participates in assigned hospital, and unit and departmental committees.
- At the discretion of department operational and patient care needs, this position is required to work rotating schedules, which may include variable hours, weekends, nights, and holidays to meet the staffing and patient care demands of a 24/7 complex health system. Regular, reliable, and punctual attendance during assigned shifts is considered an essential function of the role.
Knowledge / Skills / Abilities- Demonstrated ability to perform the essential functions as outlined above.
- Demonstrated availability to work variable and rotating shifts, including nights, weekends, and holidays, in a 24/7 patient care environment.
- Ability to provide care to the population served.
- Demonstrated knowledge of the principles of life span growth and development and the ability to assess data regarding the patient's status and provide care as described in the department's policies and procedures manual.
- Demonstrated human relations and effective communication skills.
- Demonstrated ability to collaborate with coders, physician teams and hospital staff.
- Demonstrated knowledge of state and federal regulations.
- Ability to identify and monitor trends and opportunities for documentation improvement.
QualificationsRequired- Five years of clinical and critical nursing experience.
- Bachelor's degree in Nursing or equivalency.
Licenses Required- Current license to practice as a Registered Nurse in the State of Utah, or obtain one within 90 days of hire under the interstate compact if switching residency to State of Utah. Must maintain current Interstate Compact (multi-state) license if residency is not being changed to Utah.
* Additional license requirements as determined by the hiring department.
Qualifications (Preferred)Preferred- Knowledge of ICD-9 and DRG.
Working Conditions and Physical DemandsEmployee must be able to meet the following requirements with or without an accommodation.
- This is a sedentary position in an office setting that may exert up to 10 pounds and may lift, carry, push,pull or otherwise move objects. This position involves sitting most of the time and is not exposed to adverse environmental conditions.
Physical RequirementsCarrying, Climbing, Color Determination, Crawling, Far Vision, Lifting, Listening, Manual Dexterity, Near Vision, Pulling and/or Pushing, Reaching, Sitting, Speaking, Standing, Stooping and Crouching, Tasting or Smelling, Walking
