Clinical Documentation Spec-RN

Department:

10169 Advocate Illinois Masonic Medical Center - Clinical Documentation Improvement

Status:

Full time

Benefits Eligible:

Yes

Hours Per Week:

40

Schedule Details/Additional Information:

This is a hybrid role offer 2 remote work days per week. Will be assigned to work 8 hour shifts between 7am-7pm Monday-Friday. Must have availability for flexible weekend coverage as needed.

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.

Major Responsibilities:
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.
Communicates with appropriate healthcare team members to ensure accurate and complete documentation is in the medical record

Conducts follow-up reviews of clinical documentation to ensure points of clarification and agreed upon documentation have been recorded in the patient’s chart.

Identifies the most appropriate principal diagnosis and complications including date to accurately reflect clinical acuity and risk of mortality in compliance with government regulations

Reviews clinical issues with coding staff to assign a working DRG, follows up with physicians if appropriate.

Provide daily clinical evaluation of the medical record including physician and clinical documentation, lab results, diagnostic information and treatment plan

Confers with physicians, face to face or via clinical documentation inquiry forms, regarding missing, unclear or conflicting medical record documentation to clarify the information, obtain needed documentation, present opportunities, and educate for appropriate identification of severity of illness

Responsible for the day-to-day evaluation of documentation by the Medical Staff and healthcare team in accordance with the hospital’s designated clinical documentation policies and procedures

Gather and analyze information pertinent to documentation findings and outcomes

Educates all internal customers on clinical documentation opportunities, coding and reimbursement issues, as well as performance improvement strategies.
Demonstrates knowledge of DRG payer issues, documentation opportunities, clinical documentation requirements, coding and policies and procedures.

Develops educational strategies for physicians and other members of the healthcare team regarding identified documentation opportunities to help support clinical acuity and risk of mortality within the medical record and to understand the significance of appropriate documentation

Coordinates education to all internal customers related to compliance, coding, and clinical documentation issues. Acts as a consultant to coders when additional information or documentation is needed to assign the correct DRG

Acts as a consultant to coders when additional information or documentation is needed to assign the correct DRG

Participates in continuous performance improvement and completes all required educational programs for hospital and medical staff

Maintains knowledge of current standards of care via literature review and participation in educational offerings

Research literature to identify new methods development and overall documentation enhancement

Complete required contact hours based on FTE status, within time frame

Maintains the integrity of data bases, tracks and trends response to clinical documentation and measures for performance improvement.
Assist site CDI leader in the development and reporting of performance measures to the medical staff and other departments and prepare physician specific data information, as appropriate.

Completes documentation on reviewed cases in the database.