Baptist Memorial Health Care
Specialist-Clinical Documentation III RN
Baptist Memorial Health Care, Southaven, Mississippi, United States, 38671
Specialist-Clinical Documentation III RN
Evaluates the day to day documentation practices of the Medical Staff and healthcare team on a complex patient population, and offers education and recommendations in accordance with the Clinical Documentation Program. Provides clinical expertise in the documentation and coding of diagnoses and procedures; stays abreast of coding and reimbursement changes; promotes quality coding and serves as a resource to the coding staff. Reports to the Corporate Clinical Documentation Manager. Performs other duties as assigned.
Responsibilities
Facilitates appropriate clinical documentation to support accurate diagnosis coding and service level documentation.
Performs quality mortality reviews to ensure documentation accuracy and maximize severity of illness and risk of mortality.
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; collaborates with quality departments on Patient Safety Indicators (PSI’s) and Hospital Acquired Condition (HAC) reductions.
Improves documentation specificity and acuity by educating physicians, clinicians, and other parties about complete and clear documentation, including capturing complications and comorbidities during the patient’s stay.
Works independently in a hybrid work mode—both in‑facility and remotely—with multi‑facility/entity responsibility.
Supports hospital and system initiatives and aids the HIM Department in meeting coding and billing revenue cycle requirements.
Demonstrates knowledge of disease definitions and natural history and assesses data reflective of the patient’s clinical status to identify acuity and severity of illness.
Establishes the working DRG assignments and collaborates with coding liaisons for accurate final DRG assignment.
Abides by the Standards of Ethical Coding set by the American Health Information Management Association.
Attends weekly, monthly, and/or yearly departmental meetings and educational offerings as scheduled.
Experience
Five (5) years of clinical experience in an acute care facility, pertinent and current to the patient population specialty.
Preferred/Desired
ICD coding experience; ICU or ED and/or Case Management experience at multi‑facilities.
BSN (in addition to Associate’s Degree in Nursing or higher).
Education
Associate’s Degree in Nursing or higher.
Skills
Knowledge of theories, principles, and concepts from RN program; strong computer skills; interpersonal, communication, and organizational skills.
Knowledge of ICD‑10 coding; training in coding provided.
Licensure
Current state RN licensure.
CCDS preferred but not required.
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Responsibilities
Facilitates appropriate clinical documentation to support accurate diagnosis coding and service level documentation.
Performs quality mortality reviews to ensure documentation accuracy and maximize severity of illness and risk of mortality.
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; collaborates with quality departments on Patient Safety Indicators (PSI’s) and Hospital Acquired Condition (HAC) reductions.
Improves documentation specificity and acuity by educating physicians, clinicians, and other parties about complete and clear documentation, including capturing complications and comorbidities during the patient’s stay.
Works independently in a hybrid work mode—both in‑facility and remotely—with multi‑facility/entity responsibility.
Supports hospital and system initiatives and aids the HIM Department in meeting coding and billing revenue cycle requirements.
Demonstrates knowledge of disease definitions and natural history and assesses data reflective of the patient’s clinical status to identify acuity and severity of illness.
Establishes the working DRG assignments and collaborates with coding liaisons for accurate final DRG assignment.
Abides by the Standards of Ethical Coding set by the American Health Information Management Association.
Attends weekly, monthly, and/or yearly departmental meetings and educational offerings as scheduled.
Experience
Five (5) years of clinical experience in an acute care facility, pertinent and current to the patient population specialty.
Preferred/Desired
ICD coding experience; ICU or ED and/or Case Management experience at multi‑facilities.
BSN (in addition to Associate’s Degree in Nursing or higher).
Education
Associate’s Degree in Nursing or higher.
Skills
Knowledge of theories, principles, and concepts from RN program; strong computer skills; interpersonal, communication, and organizational skills.
Knowledge of ICD‑10 coding; training in coding provided.
Licensure
Current state RN licensure.
CCDS preferred but not required.
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