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This role will facilitate the modifications of clinical documentation through extensive initial and concurrent interaction with physicians and other members of the healthcare team, to support appropriate documentation of the clinical severity and risk of mortality is captured for the level of services rendered to select inpatients populations. This role will supports timely, accurate and complete documentation of clinical information used for measuring and reporting physician and hospital outcomes and provides education to all members of the health care team on an ongoing basis.
Job Responsibility:
Improves the overall quality and completeness of clinical documentation by performing chart reviews using clinical documentation guidelines based on accepted standards, evidenced based practice, and current regulatory requirements
Educates all internal customers on clinical documentation opportunities, coding and reimbursement issues, as well as performance improvement strategies
Maintains the integrity of data bases, tracks and trends response to clinical documentation and measures for performance improvement
Demonstrate positive and effective interpersonal relations dealing with all members of the team
Requirements:
Graduate from an accredited school of nursing BSN
5 years relevant clinical experience
Current nursing license in the State of Illinois
Ability to prioritize work
Excellent communication skills
Good problem solving skills
Critical thinking skills
Basic Computer skills
Effective problem-solver with good interpersonal communication skills, verbal and written
Effective observation, analytical, and critical thinking skills
Extensive knowledge and experience of ICD-10 coding classification system and DRGs
Ability to work in changing environment
Ability to prioritize independently and respond to multiple simultaneous requests
Ability to work under stressful conditions and in difficult situations
Must have acute care facility clinical bedside nursing experience of either medical, surgical, or intensive care