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Provides concurrent review of the clinical documentation in the medical record; review the medical record with a clinical lens to identify any missing or understated diagnoses. Queries the medical staff when necessary, by written and/or verbal communication to obtain accurate and complete physician documentation that supports the patient condition(s) and treatment plan. Performs a thorough chart review to determine the appropriate principal diagnosis of the patient. Coordinates with coding/HIM/UR and other departments to achieve a record that reflects the acuity of the patient and level of care provided.
Job Responsibility:
Provides concurrent review of the clinical documentation in the medical record
review the medical record with a clinical lens to identify any missing or understated diagnoses
Queries the medical staff when necessary, by written and/or verbal communication to obtain accurate and complete physician documentation that supports the patient condition(s) and treatment plan
Performs a thorough chart review to determine the appropriate principal diagnosis of the patient
Coordinates with coding/HIM/UR and other departments to achieve a record that reflects the acuity of the patient and level of care provided
Conducts initial and follow-up concurrent reviews on inpatient admissions for opportunities to clarify documentation in the medical record for accurate reflection of the acuity of the patient and justifying the level of care
Documents findings in workflow tools, noting all key information used in the tracking process
Review medical record concurrently for documentation not yet in the record but supported by clinical indicators
Uses relationship building and strong communication skills to develop a rapport with providers to clarify information in the medical record
Uses appropriate querying templates to get needed documentation
Conducts follow-up on unanswered queries during the patient stay to obtain a response to unanswered queries
Provides education to physicians on the importance of complete documentation and key documentation concepts during regular physician meetings or on individually with physicians
Use data provided by managers, directors, and consulting team to actions to identify what is working well and areas of focus
Adheres to and supports team members in exhibiting TMCH values of integrity, community, compassion, and dedication
Adheres to TMC organizational and department-specific safety, confidentiality, values, policies and standards
Performs related duties as assigned
Requirements:
Graduation from a qualified, nationally-accredited nursing program
Three (3) years of RN clinical experience in an acute care setting
Current RN licensure permitting work in state of Arizona
Extensive clinical knowledge and understanding of pathology/physiology
Strong critical thinking skills
Knowledge of age-specific patient needs and the elements of disease processes and related procedures
Excellent written and verbal communication skills
Assertive personality traits to facilitate ongoing physician communication
Working knowledge of inpatient admission criteria
Ability to work independently in a time-oriented environment
Ability to stand and walk in the performance of job responsibilities
Demonstrates knowledge of the importance of, and makes an effort to capture, all appropriate secondary diagnoses for quality rating purposes
Nice to have:
CDI experience preferred
CCDS (Certified Clinical Documentation Specialist) from ACDIS or CDIP (Certified Documentation Improvement Practitioner) from AHIMA preferred