Clinical RN Document Specialist

Essential Job Duties

• Works collaboratively with the healthcare team to facilitate documentation within the medical record that supports the accurate patient’s severity of illness and risk of mortality.
• Identifies need to clarify documentation of records and utilizes effective communication skills with physician, case managers, nurses, coders and other healthcare professionals utilizing appropriate tools to capture needed documentation.
• Collaborates with physicians, physician assistants, and nurses/case managers to identify principal diagnosis options and secondary diagnoses for Medicare patients.
• Serves and a resource to physicians and others regarding issues related to the appropriateness of inpatient DRG assignment.
• Reviews record and works collaboratively with nurses and physicians to assure accurate documentation of quality indicators in the medical record. Responsible for proactively taking actions to assure the information is appropriately documented.
• Demonstrates current knowledge of inpatient reimbursement systems and is capable of communicating this knowledge in both verbal and written forms to physicians, their staff, case management , and staff in the Health Information Department.

Secondary Job Duties That May be Reassigned

• Other duties as assigned.

Job Specifications

• Education: Registered nurse with current licensure; Bachelors Degree in Nursing effective January 2017 (with the exception of staff previously granted grandfather status).
• Experience: One (1) year experience in a medical/surgical or emergency room area.