OSS HEALTH
Utilization Review RN/Documentation Specialist - (Full-Time)
OSS HEALTH, York, Pennsylvania, United States, 17402
Clinical Documentation Specialist- Registered Nurse (Full-Time)
The Clinical Documentation Specialist Nurse (RN) serves as an advisor to clinicians, ensuring complete and accurate inpatient documentation. Acting as a liaison between clinicians and coders, the RN-CDS fosters a mutual understanding of the various uses and implications of medical record documentation. As an expert resource, the RN-CDS provides guidance on the impact of documentation in several key areas, including patient care, quality of care metrics, accurate reimbursement, risk of mortality/severity of illness indicators, and compliance with coding standards. Under the direction of the Manager of Surgical Optimization the RN-CDS conducts concurrent reviews of inpatient medical records, adhering to state, federal, and accrediting agency requirements. Utilizing strong clinical expertise, official coding guidelines, and in-depth knowledge of risk adjustment, the RN-CDS ensures that documentation accurately reflects the patient's condition, supports appropriate reimbursement, and contributes to high-quality patient outcomes. Knowledge of, but not limited to, current coding guidelines and methodologies, MSDRG, APR-DRG, HCCs; ICD-10-CM/PCS coding guidelines and conventions. Demonstrate extensive clinical knowledge necessary to meet performance standards in the position and provide clinical documentation guidance to peers and providers Strong organization and analytical thinking skills Proficient with Microsoft Office applications (Outlook, Word, Excel, PowerPoint) Demonstrates critical thinking skills, able to assess, evaluate, and teach others. Minimum associate degree in Registered Nursing /Preferred Bachelor of Science in Nursing Work Experience Minimum Three (3) years nursing, case management, utilization review or quality resources experience in an acute care setting. Preferred Three (3) years of Clinical Documentation Integrity experience highly desirable Five (5) years nursing, case management, utilization review, or quality resources experience in an acute care setting Facilitates appropriate clinical documentation to support the severity of illness and complexity of care rendered to patients Concurrently reviews records to identify unclear, ambiguous or inconsistent documentation. Initiates verbal and/or written physician queries and conducts necessary follow up. Collaborates with coding staff on retrospective medical record review for severity, accuracy and quality issues Advises clinicians on the value of reliable, precise, complete, consistent, clear and timely documentation. Advises clinicians on the impacts of quality documentation on patient care and clinical data base integrity Collaborates with clinicians on the process by which clinical documentation is translated into codes Counsels clinicians on the effects of translation on physician and hospital quality outcome measures and hospital financial performance Tracks and trends documentation integrity metrics. Assigns "working" values for severity, risk of mortality and DRG (MS and APR) and tracks potential changes with documentation improvement Participates in the development of reports documenting the impacts of the program Identifies improvement opportunities for system functionality; creates efficiencies and communicates opportunities for improvement Assures record consistency among admission order, record description of medical necessity and patient status Functions as an expert source for information regarding the impact of documentation on patient care, severity of illness, DRG assignment and quality of care/risk adjustment metrics Ability to communicate effectively with staff, peers, physicians and the public. Ability to speak and understand English fluently. Light physical effort; some standing, walking, bending, reaching, stooping; manual dexterity to operate keyboard and other equipment; detail oriented; able to maintain a pleasant and courteous demeanor under all circumstances. The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions. Climate controlled environment with occasional periods of being outside.
The Clinical Documentation Specialist Nurse (RN) serves as an advisor to clinicians, ensuring complete and accurate inpatient documentation. Acting as a liaison between clinicians and coders, the RN-CDS fosters a mutual understanding of the various uses and implications of medical record documentation. As an expert resource, the RN-CDS provides guidance on the impact of documentation in several key areas, including patient care, quality of care metrics, accurate reimbursement, risk of mortality/severity of illness indicators, and compliance with coding standards. Under the direction of the Manager of Surgical Optimization the RN-CDS conducts concurrent reviews of inpatient medical records, adhering to state, federal, and accrediting agency requirements. Utilizing strong clinical expertise, official coding guidelines, and in-depth knowledge of risk adjustment, the RN-CDS ensures that documentation accurately reflects the patient's condition, supports appropriate reimbursement, and contributes to high-quality patient outcomes. Knowledge of, but not limited to, current coding guidelines and methodologies, MSDRG, APR-DRG, HCCs; ICD-10-CM/PCS coding guidelines and conventions. Demonstrate extensive clinical knowledge necessary to meet performance standards in the position and provide clinical documentation guidance to peers and providers Strong organization and analytical thinking skills Proficient with Microsoft Office applications (Outlook, Word, Excel, PowerPoint) Demonstrates critical thinking skills, able to assess, evaluate, and teach others. Minimum associate degree in Registered Nursing /Preferred Bachelor of Science in Nursing Work Experience Minimum Three (3) years nursing, case management, utilization review or quality resources experience in an acute care setting. Preferred Three (3) years of Clinical Documentation Integrity experience highly desirable Five (5) years nursing, case management, utilization review, or quality resources experience in an acute care setting Facilitates appropriate clinical documentation to support the severity of illness and complexity of care rendered to patients Concurrently reviews records to identify unclear, ambiguous or inconsistent documentation. Initiates verbal and/or written physician queries and conducts necessary follow up. Collaborates with coding staff on retrospective medical record review for severity, accuracy and quality issues Advises clinicians on the value of reliable, precise, complete, consistent, clear and timely documentation. Advises clinicians on the impacts of quality documentation on patient care and clinical data base integrity Collaborates with clinicians on the process by which clinical documentation is translated into codes Counsels clinicians on the effects of translation on physician and hospital quality outcome measures and hospital financial performance Tracks and trends documentation integrity metrics. Assigns "working" values for severity, risk of mortality and DRG (MS and APR) and tracks potential changes with documentation improvement Participates in the development of reports documenting the impacts of the program Identifies improvement opportunities for system functionality; creates efficiencies and communicates opportunities for improvement Assures record consistency among admission order, record description of medical necessity and patient status Functions as an expert source for information regarding the impact of documentation on patient care, severity of illness, DRG assignment and quality of care/risk adjustment metrics Ability to communicate effectively with staff, peers, physicians and the public. Ability to speak and understand English fluently. Light physical effort; some standing, walking, bending, reaching, stooping; manual dexterity to operate keyboard and other equipment; detail oriented; able to maintain a pleasant and courteous demeanor under all circumstances. The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions. Climate controlled environment with occasional periods of being outside.