Clinical Documentation Specialty RN at BEACON HEALTH SYSTEM in Granger, Indiana

Job Description:

Reports to the Director of Coding and CDET. Responsible for concurrent review of the clinical documentation in the medical records. Responsible to query the medical staff and other care givers as necessary via verbal and written communication, to obtain accurate and complete documentation which appropriately supports the severity of the patient's illness and risk of mortality.MISSION, VALUES and SERVICE GOALS

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  MISSION: We deliver outstanding care, inspire health, and connect with heart.


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  VALUES: Trust. Respect. Integrity. Compassion.


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  SERVICE GOALS: Personally connect. Keep everyone informed. Be on their team.

• Communicating with Physicians verbally, and written will be required for 95% of the concurrent queries for documentation improvement. This includes follow up with physicians after initial chart reviews for the estimated MS-DRG or APR-DRG and processing of a query form for tracking.


• Formulating credible clinical documentation clarifications to improve clinical documentation of the principal diagnoses, major and minor co-morbidities, present on admission and quality core measures.


• Assigning a working MS-DRG or APR-DRG and utilization of the appropriate software for a query form. Utilization of the software for researching diagnoses having an impact on the MS-DRG or APR-DRG and severity of the patient.


• Analyzing clinical information to identify areas within the chart for potential gaps in physician documentation.


• Following up with any query after patient discharge that could not be obtained from the physician concurrently.


• Working with the physician advisor on a routine basis to collaborate on cases and advise on discussion that the physician advisor needs to have with selected physicians.

• Interpreting on-site reports, monitoring reports and data, and other tracking information and findings at team meetings.


• Identifying areas of focus through report analysis.


• Serving as a resource to physicians and administration regarding issues related to the appropriateness of an inpatient MS-DRG or APR-DRG assignment.


• Reviewing coder analyst feedback in the appropriate software program and individual DRG tracking system reports as a means of continuous self-evaluation; discusses any issues or concerns with the Manager or Director.

• Completing other job-related assignments and special projects as assigned.


• Participating on Beacon committees as requested.

Associate complies with the following organizational requirements:

• Attends and participates in department meetings and is accountable for all information shared.


• Completes mandatory education, annual competencies and department specific education within established timeframes.


• Completes annual employee health requirements within established timeframes.


• Maintains license/certification, registration in good standing throughout fiscal year.


• Direct patient care providers are required to maintain current BCLS (CPR) and other certifi cations as required by position/department.


• Consistently utilizes appropriate universal precautions, protective equipment, and ergonomic techniques to protect patient and self.


• Adheres to regulatory agency requirements, survey process and compliance.


• Complies with established organization and department policies.


• Available to work overtime in addition to working additional or other shifts and schedules when required.

• Leverage innovation everywhere.


• Cultivate human talent.


• Embrace performance improvement.


• Build greatness through accountability.


• Use information to improve and advance.


• Communicate clearly and continuously.

• The knowledge, skills and abilities as indicated below are normally acquired through the successful completion of a nursing program from an accredited school of nursing and a current license to practice as a Registered Nurse in Indiana. A minimum of five years of clinical experience in an acute care setting is required. A recent critical care or strong recent medical/surgical background is preferred.

• Ability to pass a written clinical competency exam.


• Requires ability to independently prioritize and organize work activities.


• Demonstrates knowledge of age-specific needs and the elements of disease processes and related procedures.


• Demonstrates the clinical knowledge and understanding of pathology/physiology to perform the essential functions of the position.


• Requires advanced analytical and critical thinking skills necessary to audit patient care data, associated patient care documentation and identification of variances in standards of care.


• Requires effective and appropriate verbal and written communication skills necessary to communicate effectively with physicians and receive the required documentation results from physicians for the program.


• Demonstrates strong interpersonal communication skills verbal and written necessary in interacting effectively with hospital staff and physicians.


• Demonstrates proficiency in effectively utilizing computer systems and applications (i.e., data entry, word processing and electronic spreadsheets) and the Internet, as well as the ability to operate office equipment specific to the department's needs (i.e, copier, fax machine, calculator, etc).


• Demonstrates the ability to maintain ethical standards as reflected by maintaining confidentiality of all information regarding patients, patient's families, staff and physicians.

• Will work some hours in an office environment.


• Works in patient care areas when making rounds to review medical records.


• May be exposed to patient illnesses and bio-hazards.

• Requires the physical ability and stamina to perform the essential functions of the position. Must be able to move throughout the hospital and patient care units.