Clinical Documentation Improvement Specialist RN Job at Nationwide Children's Hospital
Overview:
Schedule: Mon-Friday, 8a-5p
This position reviews inpatient medical records and identifies opportunities in provider documentation that will clarify patient severity of illness, risk of mortality, quality indicator measures and intensity of care rendered. The Clinical Documentation Improvement Specialist collaborates with providers and HIM coding staff to ensure accurate clinical documentation by concurrently assigning APR-DRG?s and capturing documentation specificity to support diagnosis and clinical indicators in the medical record. Why Nationwide Children's Hospital?:
Here, Diversity, Equity and Inclusion are integrated into our core values and practices. We are passionate about building, sustaining and evolving an inclusive and equitable environment. We are seeking individuals who live these values and want to share their experiences and efforts in support of our collective mission.
Ask anyone with a Nationwide Children’s badge what they do for a living. They’ll tell you it’s More Than a Job. It’s a calling. It’s a chance to use and grow your talent to make an impact that truly matters. Because here, we exist simply to help children everywhere.
Nationwide Children’s Hospital. A Place to Be Proud.Responsibilities:
SKILLS:
1. Critical reasoning skills in clinical decision-making, problem solving, and ability to interpret medical record data.
EDUCATION & EXPERIENCE:
Required:
Desired:
MINIMUM PHYSICAL REQUIREMENTS:
The above list of duties is intended to describe the general nature and level of work performed by individuals assigned to this classification. It is not to be construed as an exhaustive list of duties performed by the individual so classified, nor is it intended to limit or modify the right of any supervisor to assign, direct, and control the work of employees under his/her supervision.
100% Remote, MUST LIVE AND WORK IN THE STATE OF OHIO.
Schedule: Mon-Friday, 8a-5p
FTE: 1.0 (40 hours per week)
Minimum Rate of Pay: 32/hr
This position reviews inpatient medical records and identifies opportunities in provider documentation that will clarify patient severity of illness, risk of mortality, quality indicator measures and intensity of care rendered. The Clinical Documentation Improvement Specialist collaborates with providers and HIM coding staff to ensure accurate clinical documentation by concurrently assigning APR-DRG?s and capturing documentation specificity to support diagnosis and clinical indicators in the medical record.
The moment you walk through our doors, you feel it. When you meet our patient families, you believe it. And when you talk with anyone who works here, you want to be part of it. Welcome to Nationwide Children’s Hospital,
Where Passion Meets Purpose.
Here, Diversity, Equity and Inclusion are integrated into our core values and practices. We are passionate about building, sustaining and evolving an inclusive and equitable environment. We are seeking individuals who live these values and want to share their experiences and efforts in support of our collective mission.
We’re 14,000 strong. And it takes every one of us to improve the lives of the kids we care for, and the kids around the world we’ll never meet. Kids who live healthier, fuller lives because of the knowledge we share. We know it takes
a
Collaborative Culture to deliver on our promise to provide the very best, innovative care and to foster new discoveries, made possible by the most groundbreaking research. Anywhere.
Ask anyone with a Nationwide Children’s badge what they do for a living. They’ll tell you it’s More Than a Job. It’s a calling. It’s a chance to use and grow your talent to make an impact that truly matters. Because here, we exist simply to help children everywhere.
Nationwide Children’s Hospital. A Place to Be Proud.
1. Completes initial reviews of all inpatient records within 24-48 hours of admission to: (a) evaluate documentation to assign the principal diagnosis, pertinent secondary diagnoses, and procedures for accurate
APR-DRG assignment, risk of mortality, and severity of illness, CC and MCC capture; and (b) initiate a review worksheet.
2. Conducts follow-up reviews of patients every 2?3 days to support and assign a working or final APR-DRG assignment upon patient discharge.
3. Queries physicians regarding missing, unclear, or conflicting documentation by requesting and obtaining additional documentation within the health record when needed. This can be done verbally,
electronically, or in person as appropriate.
4. Queries providers in an ethical manner to avoid potential fraud and/or compliance issues.
5. Escalates unanswered queries as appropriate to the physician advisor and follows outlined escalation process to complete queries.
6. Educates physicians and key healthcare providers regarding clinical documentation improvement and the need for accurate and complete documentation in the health record.
7. Utilizes strong critical thinking and clinical expertise to effectively communicate documentation opportunities with providers.
8. Collaborates with case managers, nursing staff, and other ancillary staff regarding interaction with physicians on documentation and to resolve physician queries prior to patient discharge.
9. Participates in the analysis and trending of statistical data for specified patient populations to identify opportunities for improvement.
10. Assists with preparation and presentation of clinical documentation monitoring/trending reports for review with physicians and hospital leadership.
11. Educates members of the patient care team regarding specific documentation needs and reporting and reimbursement issues identified through daily and retrospective documentation reviews and aggregate
data analysis
12. Facilitates change processes required to capture needed documentation, such as forms redesign.
13. Partners with the coding professionals to ensure accuracy of diagnostic and procedural data and completeness of supporting documentation to determine a working and final APR-DRG, severity of illness,
and/or risk of mortality
14. Reviews and clarifies clinical issues in the health record with the coding professionals that would support an accurate APR-DRG assignment, severity of illness, and/or risk of mortality.
15. Understands NCH quality metrics and healthcare regulations are essential to provide guidance to other hospital departments regarding documentation requirements.
Qualifications:
Qualifications
SKILLS:
1. Critical reasoning skills in clinical decision-making, problem solving, and ability to interpret medical record data.
2. Flexible, positive and clear interpersonal and communication skills with the ability to provide information in a collaborative manner with physicians and other staff.
3. Knowledge of computer-based applications including but not limited to Word, Excel, 3M encoder, EHR (Epic)
4. Organizational skills.
5. Excellent written communication skills
EDUCATION & EXPERIENCE:
Required:
1. Bachelors Degree in Nursing with current RN license in the state of Ohio or MBBS designation
2. Minimum of 5 years experience in inpatient medical/surgical or critical care setting.
Desired:
1. 10 years recent experience in a Pediatric inpatient medical/surgical or critical care setting.
2. Certification in health-related field or Clinical Documentation Improvement (RHIA, RHIT, CDIP).
3. At least 2 years of experience as a CDI Specialist.
4. HIM Coding experience.
5. Competency in ICD-10 documentation requirements.
6. CDIP credential.
7.NICU, Cardiology, Hem/Onc experience
MINIMUM PHYSICAL REQUIREMENTS:
The above list of duties is intended to describe the general nature and level of work performed by individuals assigned to this classification. It is not to be construed as an exhaustive list of duties performed by the individual so classified, nor is it intended to limit or modify the right of any supervisor to assign, direct, and control the work of employees under his/her supervision.
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