About Us
Riverside Health System is a leading healthcare provider in the Newport News, Virginia area, dedicated to delivering exceptional patient care and innovative medical solutions. Our team of compassionate professionals is committed to making a positive impact on the lives of our patients and their families. As a Registered Nurse-Clinical Documentation Specialist III, you will play a vital role in our collaborative team, working closely with healthcare providers, coding staff, and other stakeholders to ensure accurate and complete clinical documentation.
Job Summary
We are seeking an experienced and skilled Registered Nurse-Clinical Documentation Specialist III to join our team on a full-time basis. This role requires a strong and diverse skillset in clinical documentation, coding, and communication. As a hybrid remote employee, you will have the flexibility to work from home while still being an integral part of our team. If you are passionate about delivering high-quality patient care and have a strong background in clinical documentation, we encourage you to apply for this exciting opportunity.
Key Responsibilities
- Assesses clinical documentation through extensive review of the medical record to provide an accurate clinical picture of the patient, including severity of illness, risk of mortality, and resource utilization.
- Interacts with providers, nursing staff, other patient care givers, and coding staff to ensure the appropriate reimbursement is received for services rendered to patients and the clinical information utilized in profiling and reporting outcomes is complete and accurate.
- Conducts post-discharge reconciliation for comparative analysis of CDI specialist and final coding MS/APR DRG.
- Formulates appropriate clinical documentation clarifications to improve documentation of principal diagnosis, comorbidities, present on admission (POA), hospital-acquired conditions (HAC), and patient safety indicators (PSI).
- Queries providers and APP's to clarify documentation in the EMR, maintaining a query rate of at least 20% with a productivity rate average of 20 reviews per day (including new and follow-up cases).
- Works with providers and Advanced Practitioners (APP) to improve provider's clinical documentation.
- Participates in departmental education, training, and orientation sessions for the team (or others) per evaluation period.
- Assists in precepting new CDI nurses when needed and serves as a subject matter expert for CDI.
- Assists in overall quality, timeliness, and completeness of the quality health record to ensure appropriate data, provider communication, and quality outcomes.
- Collaborates with healthcare team to ensure physician queries are resolved prior to discharge.
- Analyzes clinical information to identify areas within the chart for potential gaps in physician documentation.
- Working knowledge of Microsoft Office Suite, including Excel, Word, PowerPoint, and Outlook, is required.
- Identifies ongoing documentation improvement opportunities.
- Creates and manages review process and support tools.
- Upholds the Standards of Conduct and Corporate Compliance.
- Supports and assists the Quality department.
- Acts as a consultant to coding professionals when additional information or documentation is needed to assign coded data.
- Conducts post-discharge reconciliation for comparative analysis of CDI specialist and HIM MS/APR DRG.
- Reviews clinical issues when appropriate with coding staff to assign a working DRG and/or clarification of documentation.
- Demonstrates initiative to improve quality and customer service by striving to exceed customer expectations.
- Institutes coaching sessions or corrective action plans as necessary.
- Proactively develops a reciprocal relationship with the Coding Professionals to ensure accuracy of diagnostic and procedural data through completeness of supporting documentation.
- Performs patient chart reviews during absences and when coverage is necessary.
- Queries providers and APP's to clarify documentation in the EMR.
- Precepts new CDI nurses and serves as a subject matter expert for CDI.
- Participates and provides input regarding CDI program activities, and attendance at routine team meetings.
- Composes and initiates AHIMA-compliant queries.
- Maintains personal and professional education and growth.
- Other duties as assigned.
Qualifications
To be considered for this role, you must meet the following qualifications:
- Education: Associates Degree, Nursing (Required); Bachelors Degree, Nursing or healthcare-related (Preferred).
- Experience: 5-6 years Acute Care Nursing (Required); 3-4 years CDI experience (Required); 3-4 years ICD-10-CM & ICD-10-PCS experience (Required); 1 year 3M 360 experience (Preferred).
- Licenses and Certifications: Registered Nurse (RN) - Virginia Department of Health Professions (VDHP) Upon Hire (Required); Certified Documentation Integrity Practitioner (CDIP) - The American Health Information Management Association (AHIMA) Upon Hire (Required) or Certified Clinical Document Specialist (CD) - Association of Clinical Documentation Integrity Specialists (ACDIS) Upon Hire (Required).
Skills and Competencies
To succeed in this role, you will need to possess the following skills and competencies:
- Strong verbal communication skills.
- Knowledge of basic nursing principles and protocols.
- Proficient in clinical practice protocols for medical procedures and patient care.
- Time management and decision-making skills (Medium proficiency).
- Excellent organizational skills with an attention to detail.
- Understanding the implications of new information for both current and future problem-solving and decision-making.
- Utilize extensive understanding of documentation requirements and guidelines in accordance with the Coding Clinic to improve the overall quality and completeness of clinical documentation by performing concurrent stay reviews.
- Familiarity with the organization of medical records, medical terminology, and disease process.
- Talking to others to convey information effectively.
- Ability to work effectively as team members with physicians and other staff.
- Ability to sit for extended periods of time.
- Able to establish good customer relationships with trust and respect.
- Strong clinical assessment and critical thinking skills.
Career Growth Opportunities and Learning Benefits
Riverside Health System is committed to the growth and development of our employees. As a Registered Nurse-Clinical Documentation Specialist III, you will have opportunities to:
- Participate in departmental education, training, and orientation sessions for the team (or others) per evaluation period.
- Assist in precepting new CDI nurses when needed and serve as a subject matter expert for CDI.
- Participate and provide input regarding CDI program activities, and attendance at routine team meetings.
- Maintain personal and professional education and growth.
Work Environment and Company Culture
Riverside Health System is a dynamic and supportive work environment that values collaboration, innovation, and excellence. As a hybrid remote employee, you will have the flexibility to work from home while still being an integral part of our team. Our company culture is built on the following values:
- EXCELLENCE: We strive to be the best at what we do and a model for others to emulate.
- CUSTOMER FOCUS: We are committed to delivering exceptional patient care and exceeding customer expectations.
- TEAMWORK: We work collaboratively with our colleagues to achieve our goals and support each other in our roles.
- INNOVATION: We encourage creativity, innovation, and continuous improvement in all aspects of our work.
- RESPECT: We treat each other with respect, dignity, and compassion, and value diversity and inclusion in our workplace.
Compensation, Perks, and Benefits
Riverside Health System offers a competitive salary and a comprehensive benefits package, including:
- Health, dental, and vision insurance.
- Retirement savings plan with employer match.
- Flexible paid time off and holidays.
- Professional development opportunities and education assistance.
- Employee recognition and reward programs.
Conclusion
We are excited to offer this opportunity to join our team as a Registered Nurse-Clinical Documentation Specialist III. If you are passionate about delivering high-quality patient care and have a strong background in clinical documentation, we encourage you to apply for this exciting opportunity. Please submit your application today and take the first step towards a rewarding new role with Riverside Health System.
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