Clinical Documentation Specialist RN - Inpatient
Billings Clinic

Billings, Montana

Posted in Health and Safety


This job has expired.

Job Info


This position may be eligible for a sign-on incentive, tuition loan repayment, and relocation assistance

The Clinical Documentation Specialist - Inpatient will conduct concurrent review of clinical documentation in the inpatient medical record with the goal to obtain the most accurate and complete physician documentation that appropriately supports the severity of a patient's illness, mortality risk, and proper reimbursement. Responsible to query physicians and other caregivers via written and/or verbal communications for clarification of clinical documentation. The CDI Specialist works collaboratively with the coding and compliance departments to ensure appropriate final DRG assignments and CC/MCC capture. In collaboration with the RN CCs team will provide ongoing education related to documentation requirements and opportunities to all provider requirements and opportunities to all providers. Will conduct concurrent and retrospective medical record review for defined patient populations to identify opportunities to improve accuracy of practitioner documentation.

Essential Job Functions

• Supports and models behaviors consistent with Billings Clinic's mission, vision, values, code of
• Meets all mandatory organizational and departmental requirements.
• Maintains competency in all organizational, departmental, and outside agency
• Performs admission reviews within 24 to 48 hours for patient populations to facilitate
• Conducts ongoing reviews of physician/provider and other clinical documentation, lab results,
• Queries physicians and non-physician providers verbally and in writing daily according to
• Validates that follow-through of accurate documentation has occurred and reports appropriately.
• In collaboration with physicians and coding specialists, identifies and records principal diagnosis,
• Provides education to physicians in a one to one setting regarding documentation specificity and the
• Utilizes medical staff established criteria for complications to assist in appropriate documentation
• Collaborates with clinical coordinator and RN CCS with the coding staff and provides clinical
• Acts as a liaison between coding staff and physicians to resolve questions about documentation and/or coding.??
• Reviews previous Billings Clinic encounters and supporting information in the concurrent electronic
• Ensures appropriate documentation exists for any conditions that were present on admission (POA).
• Participates in process improvement activities with department leadership, department team members, and inter-departmental team members.
• Identifies needs and sets goals for own growth and development; meets all mandatory organizational and departmental requirements.
• Maintains competency in all organizational, departmental, and outside agency environmental, employee, or p patient safety standards relevant to job performance.
• Performs other duties as assigned or needed to meet the needs of the department/organization

Minimum Qualifications

Education

• Graduate of an accredited school of nursing, Bachelors degree in nursing is preferred. Associate (or Diploma) RNs hired into this position must commit to completing their Bachelor of Nursing degree within 4 years after their hire date. Billings Clinic will help support the cost through financial assistance.

Experience

• Three (3) years of medical/surgical nursing experience with at least one year of Billings Clinic experience preferred but not required.

Certifications and Licenses

• Certified Coding Specialist CCS, Within 2 years of hire
• Certified Clinical Documentation Specialist (CCDS) Within 2 years of hire
• Certified Documentation Improvement Practitioner (CDIP), Within 2 years of hire
• Certified Professional Coder (CPC), Within 2 years of hire
• Current Montana state license as a registered nurse required by start date


This job has expired.

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