Senior Clinical Documentation Specialist (RN)

Remote, USA Full-time
Job Summary: Responsible for improving the overall quality and completeness of clinical documentation. Facilitates modifications to clinical documentation through extensive interaction with physicians, nursing staff, other patient caregivers, and medical records coding staff to ensure that compliant documentation is achieved, with resultant appropriate level of severity reflected and reimbursement received for service rendered to all patients with a DRG based payor. Job Responsibilities: -Ensures the accuracy and completeness of clinical information used for measuring and reporting physician and hospital outcomes. -Assists the Case Management Manager in the day to day responsibilities of overseeing the Documentation Specialists. -Includes, but is not limited to, participation in the Documentation Specialist performance appraisal process, supervision of workload assignments, and practice supervision. -Plans and implements compliant documentation goals and objectives across the Community Hospital Division (CHD), which support hospital goals and objectives. -Assists in development of agendas and in material preparations for meetings to support hospital improvements in identified hospital initiatives, including CDE System Steering Committee. -Coordinates and manages program reporting and outcome measurements. -Assists the Case Management Manager in the development and updating of policies, procedures and workflow. -Facilitates modifications to clinical documentation to ensure compliant documentation with appropriate reimbursement received for the level of service rendered to all patients with a DRG based payor. -Improves the overall quality and completeness of clinical documentation, ensuring documentation integrity, by performing initial reviews, continued stays reviews and reconciliation process using the 3M 360 Program. -Coordinates professional growth for the Community Hospital Division - RN Clinical Documentation Specialists through appropriate educational opportunities. -Coordinates staff development activities related to education, quality assurance and outcome measurements. -Coordinates staff development activities related to education, quality assurance and outcome measurements. -Facilitates communication and confers with providers face to face or via Clinical Documentation Excellence (CDE) Shared Note to clarify diagnoses information, obtain needed documentation, present opportunities and educate for appropriate DRG based on severity of illness (SOI) and risk of mortality (ROM). -Reviews patient record to ensure points of clarification have been recorded. -Educates all internal customers on compliant documentation opportunities, coding and reimbursement issues, as well as performance improvement methodologies. -Assists with staff recruitment and interviewing RN Clinical Documentation Specialists ( CDS) candidates. -Serves as Primary lead for orientation and training for new RN CDS. -Assists with management of 3M 360 program and serves as subject matter expert with IT on resolution. when operations impacted. -Other duties as assigned. Skills: Required Skills & Experience: -A minimum of five (5) years in an acute care setting as an RN. -Working knowledge of computers. Preferred Skills & Experience: -Coding experience, i.e. CCS, RHIT background. Education: Required Education: -Associate degree in Nursing. Preferred Education: -Bachelor's degree in Nursing. Required Certifications & Licensure: -Requires current state of Wisconsin Registered Nurse License or a Multi-state Nursing License from a participating state in the NLC (Nurse Licensure Compact). -Advanced certification related to CDI (CCDS, CDIP) is required within 6 months of hire. Job Types: Full-time, Contract Pay: $55.00 - $64.00 per hour Application Question(s): • Please share the best contact number and the most convenient time to connect over a call. Work Location: Remote Apply tot his job
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