Registered Nurse (RN) | Clinical Documentation Specialist

Avera Health

Worker Type:

Regular

Work Shift:

Day Shift (United States of America)

Pay Range:

The pay range for this position is listed below. Actual pay rate dependent upon experience.

$31.00 - $46.25

Position Highlights

You Belong at Avera

Be part of a multidisciplinary team built with compassion and the goal of Moving Health Forward for you and our patients. Work where you matter.

A Brief Overview

The RN-Clinical Documentation Specialist (CDI) reviews medical records to ensure accuracy and completeness of the medical records to ensure accurate coding of the record. CDI role is complex and requires expert knowledge of clinical care and applicable coding guidelines, as well as an ability to communicate effectively with the clinical team. This role collaborates with clinicians, physicians, and HIM coding staff to ensure timely and accurate documentation and provides training and education as needed. Demonstrates a willingness to maintain awareness of the business of medicine and transitional healthcare changes including but not limited to value-based purchasing, accountable care organizations and the readmission reduction program.

What you will do

• Accurately reviews the entire inpatient medical record (dictation, templates, lab, orders, and nursing notes) to determine appropriate coding utilizing: ICD-9-CM, ICD-10 (CM and PCS), DRG Grouper and APR-DRG Grouper for strategizing SOI, ROM and DRG assignment.
• Utilizing advanced experience and in-depth knowledge, accurately determines the appropriate sequence of principle diagnosis code, procedure codes, MS-DRG/APR- DRG, SOI, ROM and POA reporting on Inpatient Coding Product Lines. Concurrent coding may be required on all product lines.
• Familiarity with Inpatient Prospective Payment System (IPPS), including new CMS guidelines related to clinical documentation, coding and reimbursement.
• Serves as a resource and provides subject matter expertise to Providers, HIM and/or coders, and other clinical entities as needed. Prompts providers/physicians/residents regarding missing, unclear, or conflicting medical record documentation and obtains additional documentation with the medical record when needed.
• Devoted to ongoing, continuous learning and provides relevant updates and happenings in the business of medicine directly impacting physicians such as documentation, CDI guidelines, coding guidelines, and CDI and coding policies.
• Maintains personal quality and production statistics in accordance to CDI standards.
• Ability and willingness to seek out changes in healthcare reform and coding regulations then incorporate those changes into chart review and educational responsibilities.
• Ability to conduct independent research to promote knowledge of clinical topics, coding guidelines, regulatory policies and trends, and healthcare economics.
• Performs and participates in performance improvement activities, such as identifying documentation requirements for the legal record.

Essential Qualifications

The individual must be able to work the hours specified. To perform this job successfully, an individual must be able to perform each essential job function satisfactorily including having visual acuity adequate to perform position duties and the ability to communicate effectively with others, hear, understand and distinguish speech and other sounds. These requirements and those listed above are representative of the knowledge, skills, and abilities required to perform the essential job functions. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential job functions, as long as the accommodations do not cause undue hardship to the employer.

Required Education, License/Certification, or Work Experience:

• Certified Clinical Documentation Specialist (CCDS) - Association of Clinical Documentation Integrity Specialists (ACDIS) within 3 Years
• Registered Nurse (RN) - Board of Nursing An active license in the state of practice Upon Hire

Preferred Education, License/Certification, or Work Experience:

• 4-6 years Related inpatient clinical experience Knowledge of hospital revenue cycle and the electronic health record.

Expectations and Standards

• Commitment to the daily application of Avera’s mission, vision, core values, and social principles to serve patients, their families, and our community.
• Promote Avera’s values of compassion, hospitality, and stewardship.
• Uphold