Baptist Memorial Health Care
Specialist-Clinical Documentation III RN
Baptist Memorial Health Care, Starkville, Mississippi, us, 39760
Specialist-Clinical Documentation III RN
Job Summary:
Evaluate the day-to-day documentation practices of the medical staff and healthcare team for a complex patient population. Offer education and recommendations in alignment with the Clinical Documentation Program. Provide clinical expertise in the documentation and coding of diagnoses and procedures, stay current on coding and reimbursement changes, promote quality coding, and serve as a resource to the coding staff. Report to the Corporate Clinical Documentation Manager and perform additional duties as assigned.
Responsibilities
Facilitate appropriate clinical documentation to support accurate diagnosis coding and ensure the level of service rendered to all patients is properly recorded.
Conduct quality mortality reviews to verify documentation accuracy and maximize severity of illness and risk of mortality metrics.
Perform reviews for risk adjustment model indicators such as CMS quality measures, present-on-admission, pay-for-performance, value‑based purchasing, and other national reporting initiatives. Collaborate with hospital performance improvement and quality departments on Patient Safety Indicators (PSIs) and Hospital‑Acquired Conditions (HACs) reduction.
Improve documentation specificity and acuity by educating physicians, clinicians, and other stakeholders on the necessity of complete and clear documentation throughout a patient’s stay, including capturing complications/comorbidities.
Work independently in a hybrid mode—both in‑facility and remotely—and assume multi‑facility or entity responsibilities.
Act as a member of the clinical team supporting specific hospital and system initiatives and assist the HIM Department in meeting coding and billing revenue‑cycle deadlines.
Demonstrate knowledge of disease definition principles and natural history, assess data reflective of a patient’s clinical status, and interpret information needed to determine acuity and severity of illness.
Establish working DRG assignments and, when applicable, collaborate with coding liaison to determine accurate final DRG assignment.
Adhere to the Standards of Ethical Coding set forth by the American Health Information Management Association.
Attend weekly, monthly, or yearly departmental meetings and scheduled educational offerings.
Requirements Experience (Minimum)
Five (5) years of clinical experience in an acute‑care facility, relevant and current to the patient population specialty.
Experience (Preferred)
ICD coding experience, ICU or ED and/or case‑management experience across multiple facilities.
Education (Minimum)
Associate’s Degree in Nursing or higher.
Education (Preferred)
BSN.
Licensure (Minimum)
Current state RN licensure.
Licensure (Preferred)
CCDS preferred but not required.
Skills
Knowledge of nursing theories, principles, and concepts from RN program completion.
Strong computer skills.
Excellent interpersonal, communication, and organizational skills.
Knowledge of ICD‑10 coding preferred; content training will be provided.
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Evaluate the day-to-day documentation practices of the medical staff and healthcare team for a complex patient population. Offer education and recommendations in alignment with the Clinical Documentation Program. Provide clinical expertise in the documentation and coding of diagnoses and procedures, stay current on coding and reimbursement changes, promote quality coding, and serve as a resource to the coding staff. Report to the Corporate Clinical Documentation Manager and perform additional duties as assigned.
Responsibilities
Facilitate appropriate clinical documentation to support accurate diagnosis coding and ensure the level of service rendered to all patients is properly recorded.
Conduct quality mortality reviews to verify documentation accuracy and maximize severity of illness and risk of mortality metrics.
Perform reviews for risk adjustment model indicators such as CMS quality measures, present-on-admission, pay-for-performance, value‑based purchasing, and other national reporting initiatives. Collaborate with hospital performance improvement and quality departments on Patient Safety Indicators (PSIs) and Hospital‑Acquired Conditions (HACs) reduction.
Improve documentation specificity and acuity by educating physicians, clinicians, and other stakeholders on the necessity of complete and clear documentation throughout a patient’s stay, including capturing complications/comorbidities.
Work independently in a hybrid mode—both in‑facility and remotely—and assume multi‑facility or entity responsibilities.
Act as a member of the clinical team supporting specific hospital and system initiatives and assist the HIM Department in meeting coding and billing revenue‑cycle deadlines.
Demonstrate knowledge of disease definition principles and natural history, assess data reflective of a patient’s clinical status, and interpret information needed to determine acuity and severity of illness.
Establish working DRG assignments and, when applicable, collaborate with coding liaison to determine accurate final DRG assignment.
Adhere to the Standards of Ethical Coding set forth by the American Health Information Management Association.
Attend weekly, monthly, or yearly departmental meetings and scheduled educational offerings.
Requirements Experience (Minimum)
Five (5) years of clinical experience in an acute‑care facility, relevant and current to the patient population specialty.
Experience (Preferred)
ICD coding experience, ICU or ED and/or case‑management experience across multiple facilities.
Education (Minimum)
Associate’s Degree in Nursing or higher.
Education (Preferred)
BSN.
Licensure (Minimum)
Current state RN licensure.
Licensure (Preferred)
CCDS preferred but not required.
Skills
Knowledge of nursing theories, principles, and concepts from RN program completion.
Strong computer skills.
Excellent interpersonal, communication, and organizational skills.
Knowledge of ICD‑10 coding preferred; content training will be provided.
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