Aiken Regional Medical Centers
Clinical Documentation Improvement RN
Aiken Regional Medical Centers, Aiken, South Carolina, United States, 29805
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Clinical Documentation Improvement RN
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Aiken Regional Medical Centers
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Position Description Responsible for improving the overall quality and completeness of clinical documentation. Promotes a partnership between the concurrent clinical reviewers, medical record coders, and physicians to improve documentation and reimbursement for ARMC. Facilitates clarification and specificity to clinical documentation through appropriate interaction with physicians, advocating for appropriate reimbursement. Supports the accuracy and completeness of the clinical information used for measuring and reporting physician and hospital outcomes to reflect the patient’s true severity of illness, intensity of care, and risk of mortality. Educates all members of the health care team on an ongoing basis.
Duties
Provides concurrent review of the clinical documentation in the medical record and queries the medical staff as necessary via written/verbal communication to obtain accurate and complete physician documentation to support severity of illness and risk of mortality in the DRG Assurance program.
Collaborates with physician, physician extender, nurse, case manager/utilization reviewer and Medical Records coder to identify principal diagnosis options, secondary diagnoses and procedures, to assign working DRGs for at least 85% of the identified populations. Able to utilize inpatient admission criteria to assign only diagnoses that meet acute care criteria.
Completes the DRG worksheet and reviews documentation in the medical record according to schedule. Updates information in Documentation Improvement tracking system in a timely manner.
Utilizes monitoring tools to track the progress of the DRG Assurance program, through interpretation of DRG tracking reports, monitoring reports and data. Shares findings with identified staff at DRG Assurance meetings. Able to identify areas of focus through report analysis. Serves as a resource to physicians and administration regarding issues related to the appropriateness of inpatient DRG assignment.
Assists in the development of APR/DRG query response physician reports. Maintains complete confidentiality of patient information, in addition to hospital and individual physician practice pattern data.
Performs other duties as assigned.
Benefit Highlights
Unlimited Employee Referral Bonus Program
Competitive Compensation & Generous Paid Time Off
Excellent Medical, Dental, Vision and Prescription Drug Plans
Tuition/Certification Reimbursement after 6 months
Culture of Excellence - Employee Recognition program
Challenging and rewarding work environment
Clinical Nursing Ladder opportunities
SoFi student loan refinancing program
401(K) with company match and discounted stock plan
Career development opportunities within UHS and its 300+ Subsidiaries!
More information is available on our Benefits Guest Website: uhsguest.com
About Universal Health Services One of the nation’s largest and most respected providers of hospital and healthcare services, Universal Health Services, Inc. (NYSE: UHS) has built an impressive record of achievement and performance, growing since its inception into a Fortune 500 corporation. Headquartered in King of Prussia, PA, UHS has 99,000 employees. Through its subsidiaries, UHS operates 28 acute care hospitals, 331 behavioral health facilities, 60 outpatient and other facilities in 39 U.S. States, Washington, D.C., Puerto Rico and the United Kingdom.
Qualifications
Graduate of nursing program. BSN Preferred.
Minimum of 5 years recent clinical experience in an acute care setting. Critical Care or Medical/Surgical preferred AND 3-5 years experience with inpatient coding and DRG guidelines.
Registered Nurse with current S.C. license AND RHIA, RHIT, CDIP, CCDS or CCS preferred.
Excellent written/verbal communication skills. Excellent critical thinking skills, must be detail oriented. Knowledge of age-specific needs and elements of disease processes and related procedures required. Strong broad-based clinical knowledge and understanding of pathology/physiology of disease processes. Ability to work independently in a time-oriented environment is essential. Working knowledge of Medicare reimbursement system and coding guidelines preferred. Computer literacy essential.
EEO Statement All UHS subsidiaries are committed to providing an environment of mutual respect where equal employment opportunities are available to all applicants and teammates. UHS subsidiaries are equal opportunity employers and as such, openly support and fully commit to recruitment, selection, placement, promotion and compensation of individuals without regard to race, color, religion, age, sex (including pregnancy, gender identity, and sexual orientation), genetic information, national origin, disability status, protected veteran status or any other characteristic protected by federal, state or local laws.
Avoid and Report Recruitment Scams We are aware of a scam whereby imposters are posing as Recruiters from UHS, and our subsidiary hospitals and facilities. Beware of anyone requesting financial or personal information. At UHS and all our subsidiaries, our Human Resources departments and recruiters are here to help prospective candidates by matching skill set and experience with the best possible career path at UHS and our subsidiaries. During the recruitment process, no recruiter or employee will request financial or personal information (e.g., Social Security Number, credit card or bank information, etc.) from you via email. Our recruiters will not email you from a public webmail client like Hotmail, Gmail, Yahoo Mail, etc. If you suspect a fraudulent job posting or job-related email mentioning UHS or its subsidiaries, we encourage you to report such concerns to appropriate law enforcement. We encourage you to refer to legitimate UHS and UHS subsidiary career websites to verify job opportunities and not rely on unsolicited calls from recruiters.
Seniority Level Mid-Senior level
Employment Type Full-time
Job Function Health Care Provider
Industries Hospitals and Health Care
Referrals increase your chances of interviewing at Aiken Regional Medical Centers by 2x
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Clinical Documentation Improvement RN
role at
Aiken Regional Medical Centers
1 day ago Be among the first 25 applicants
Get AI-powered advice on this job and more exclusive features.
Position Description Responsible for improving the overall quality and completeness of clinical documentation. Promotes a partnership between the concurrent clinical reviewers, medical record coders, and physicians to improve documentation and reimbursement for ARMC. Facilitates clarification and specificity to clinical documentation through appropriate interaction with physicians, advocating for appropriate reimbursement. Supports the accuracy and completeness of the clinical information used for measuring and reporting physician and hospital outcomes to reflect the patient’s true severity of illness, intensity of care, and risk of mortality. Educates all members of the health care team on an ongoing basis.
Duties
Provides concurrent review of the clinical documentation in the medical record and queries the medical staff as necessary via written/verbal communication to obtain accurate and complete physician documentation to support severity of illness and risk of mortality in the DRG Assurance program.
Collaborates with physician, physician extender, nurse, case manager/utilization reviewer and Medical Records coder to identify principal diagnosis options, secondary diagnoses and procedures, to assign working DRGs for at least 85% of the identified populations. Able to utilize inpatient admission criteria to assign only diagnoses that meet acute care criteria.
Completes the DRG worksheet and reviews documentation in the medical record according to schedule. Updates information in Documentation Improvement tracking system in a timely manner.
Utilizes monitoring tools to track the progress of the DRG Assurance program, through interpretation of DRG tracking reports, monitoring reports and data. Shares findings with identified staff at DRG Assurance meetings. Able to identify areas of focus through report analysis. Serves as a resource to physicians and administration regarding issues related to the appropriateness of inpatient DRG assignment.
Assists in the development of APR/DRG query response physician reports. Maintains complete confidentiality of patient information, in addition to hospital and individual physician practice pattern data.
Performs other duties as assigned.
Benefit Highlights
Unlimited Employee Referral Bonus Program
Competitive Compensation & Generous Paid Time Off
Excellent Medical, Dental, Vision and Prescription Drug Plans
Tuition/Certification Reimbursement after 6 months
Culture of Excellence - Employee Recognition program
Challenging and rewarding work environment
Clinical Nursing Ladder opportunities
SoFi student loan refinancing program
401(K) with company match and discounted stock plan
Career development opportunities within UHS and its 300+ Subsidiaries!
More information is available on our Benefits Guest Website: uhsguest.com
About Universal Health Services One of the nation’s largest and most respected providers of hospital and healthcare services, Universal Health Services, Inc. (NYSE: UHS) has built an impressive record of achievement and performance, growing since its inception into a Fortune 500 corporation. Headquartered in King of Prussia, PA, UHS has 99,000 employees. Through its subsidiaries, UHS operates 28 acute care hospitals, 331 behavioral health facilities, 60 outpatient and other facilities in 39 U.S. States, Washington, D.C., Puerto Rico and the United Kingdom.
Qualifications
Graduate of nursing program. BSN Preferred.
Minimum of 5 years recent clinical experience in an acute care setting. Critical Care or Medical/Surgical preferred AND 3-5 years experience with inpatient coding and DRG guidelines.
Registered Nurse with current S.C. license AND RHIA, RHIT, CDIP, CCDS or CCS preferred.
Excellent written/verbal communication skills. Excellent critical thinking skills, must be detail oriented. Knowledge of age-specific needs and elements of disease processes and related procedures required. Strong broad-based clinical knowledge and understanding of pathology/physiology of disease processes. Ability to work independently in a time-oriented environment is essential. Working knowledge of Medicare reimbursement system and coding guidelines preferred. Computer literacy essential.
EEO Statement All UHS subsidiaries are committed to providing an environment of mutual respect where equal employment opportunities are available to all applicants and teammates. UHS subsidiaries are equal opportunity employers and as such, openly support and fully commit to recruitment, selection, placement, promotion and compensation of individuals without regard to race, color, religion, age, sex (including pregnancy, gender identity, and sexual orientation), genetic information, national origin, disability status, protected veteran status or any other characteristic protected by federal, state or local laws.
Avoid and Report Recruitment Scams We are aware of a scam whereby imposters are posing as Recruiters from UHS, and our subsidiary hospitals and facilities. Beware of anyone requesting financial or personal information. At UHS and all our subsidiaries, our Human Resources departments and recruiters are here to help prospective candidates by matching skill set and experience with the best possible career path at UHS and our subsidiaries. During the recruitment process, no recruiter or employee will request financial or personal information (e.g., Social Security Number, credit card or bank information, etc.) from you via email. Our recruiters will not email you from a public webmail client like Hotmail, Gmail, Yahoo Mail, etc. If you suspect a fraudulent job posting or job-related email mentioning UHS or its subsidiaries, we encourage you to report such concerns to appropriate law enforcement. We encourage you to refer to legitimate UHS and UHS subsidiary career websites to verify job opportunities and not rely on unsolicited calls from recruiters.
Seniority Level Mid-Senior level
Employment Type Full-time
Job Function Health Care Provider
Industries Hospitals and Health Care
Referrals increase your chances of interviewing at Aiken Regional Medical Centers by 2x
#J-18808-Ljbffr