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Facilitates clinical documentation improvement through concurrent and retrospective interaction with physicians and members of the healthcare team. This interaction supports the clinical severity of the inpatient admission, quality documentation standards that align with federal and state regulations and assists with maximizing revenue.
Job Responsibility:
Facilitates clinical documentation improvement through concurrent and retrospective interaction with physicians and members of the healthcare team
Recognizes gaps and facilitates modifications in clinical documentation that support accuracy of medical conditions for inpatient encounter
Recognizes documentation opportunities with the assistance of computer software
Conducts clinical documentation improvement efforts through query processes
Provides oversight for EPARC, including UM work queues and unbilled work queues
Communicates with individual physicians and medical team, providing guidance and clarification around principal diagnoses, complicating conditions, and diagnoses being treated to ensure complete and accurate documentation in medical record
Presents overall findings to key stakeholders, including leadership and peers
Provides education to peers and healthcare team members for documentation improvement, reimbursement opportunities, and overall performance improvement
Demonstrates knowledge of trends in clinical diagnoses that results in payer denials
Ensures validity of data for reporting and measuring physician and hospital outcomes using computer software and analysis of data
Audits clinical documentation to confirm points of clarification have been entered in the medical record
Meets established productivity expectations of CDI program
Maintains knowledge of hospital clinical practice guidelines to support the most thorough review of the medical record
Requirements:
Associate's degree Registered Nurse (RN) required
Bachelor's degree in Nursing preferred
5 years inpatient clinical experience, knowledge of complex disease processes required
Or equivalent combination of education and experience
Prior experience with EPARC, eRecord, HDM, Cobius, and Sharepoint preferred
Current RN License in NYS upon hire required
Nice to have:
Bachelor's degree in Nursing
Prior experience with EPARC, eRecord, HDM, Cobius, and Sharepoint