Mayhill Hospital
Clinical Documentation Improvement RN
Mayhill Hospital, Aiken, South Carolina, United States, 29805
Position Description
Responsible for improving the overall quality and completeness of clinical documentation at Aiken Regional Medical Centers (ARMC). Promotes partnership between concurrent clinical reviewers, medical record coders, and physicians to enhance documentation and reimbursement. Facilitates clarification and specificity in clinical documentation, advocates for appropriate reimbursement, and supports the accuracy and completeness of data used for measuring and reporting physician and hospital outcomes. Educates all members of the health care team on an ongoing basis.
Aiken Regional Medical Centers, located in Aiken, South Carolina, is a 273‑bed acute care facility that has provided top‑quality and safe healthcare to the residents of Aiken and surrounding communities since 1917. ARMC has been ranked a top hospital in South Carolina by the American Heart Association for its treatment of heart attack, heart failure, stroke, and coronary artery disease. The hospital also provides comprehensive services such as behavioral health (Aurora Pavilion Behavioral Health), emergency medical care (main hospital and ER at Sweetwater), orthopedic surgeries, maternity, rehabilitation services (Hitchcock Rehabilitation Services), imaging, and wound care.
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
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.
Pay Transparency To encourage pay transparency, promote pay equity, and proactively address regulations, UHS and all our subsidiaries will comply with all applicable state or local laws or regulations which require employers to provide wage or salary range information to job applicants and employees. Salary offers may be based on key factors such as education and related experience.
Visit Us Online Visit us online at:
https://www.aikenregional.com
#J-18808-Ljbffr
Aiken Regional Medical Centers, located in Aiken, South Carolina, is a 273‑bed acute care facility that has provided top‑quality and safe healthcare to the residents of Aiken and surrounding communities since 1917. ARMC has been ranked a top hospital in South Carolina by the American Heart Association for its treatment of heart attack, heart failure, stroke, and coronary artery disease. The hospital also provides comprehensive services such as behavioral health (Aurora Pavilion Behavioral Health), emergency medical care (main hospital and ER at Sweetwater), orthopedic surgeries, maternity, rehabilitation services (Hitchcock Rehabilitation Services), imaging, and wound care.
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
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.
Pay Transparency To encourage pay transparency, promote pay equity, and proactively address regulations, UHS and all our subsidiaries will comply with all applicable state or local laws or regulations which require employers to provide wage or salary range information to job applicants and employees. Salary offers may be based on key factors such as education and related experience.
Visit Us Online Visit us online at:
https://www.aikenregional.com
#J-18808-Ljbffr