Why work for Nebraska Methodist Health System?
At Nebraska Methodist Health System, we focus on providing exceptional care to the communities we serve and people we employ. We call it The Meaning of Care – a culture that has and will continue to set us apart. It’s helping families grow by making each delivery special, conveying a difficult diagnosis with a compassionate touch, going above and beyond for a patient’s needs, or giving a high five when a patient beats a disease or conquers a personal health challenge. We offer competitive pay, excellent benefits and a great work environment where all employees are valued! Most importantly, our employees are part of a team that makes a real difference in the communities we live and work in.

Job Summary:

Location: Methodist Hospital
Address: 8303 Dodge St. - Omaha, NE

Work Schedule: Mon - Fri, daytime business hours

Responsible for concurrent review of clinical documentation for all selected admissions.

Responsibilities:

Essential Functions

1. Performs concurrent review of clinical documentation for all selected admissions to ensure documentation supports and accurately reflects all disease processes being treated or affecting care while the patient is hospitalized by analyzing documentation for incompleteness, identifying ambiguous, conflicting or clinically incongruent documentation and ensure the documentation supports treatment being provided.

• 25-30 reviews performed daily.

2. Assists with the development of physician queries to ensure compliance with the query process in an effort to obtain the correct clinical diagnoses and capture of severity of illness by incorporating clinical indications and clinical knowledge in the development of the query.

• Demonstrates knowledge of an appropriate worded query that meets regulatory, legal and ethical standards.

3. Initiates assertive professional communication with physicians when documentation is unclear, incomplete or lacks the necessary completeness to assign ICD9 codes by completing query form or face-to-face communication with the physician.

• Feedback and/or observation by supervisor of communication approach, clinical knowledge and professionalism.

4. Tracks responses to questions on documentation by trending compliance with documentation queries in an effort to identify opportunities for physician feedback and education.

• Number of MD responses to query.
• Number of changes to documentation.
  • Principle diagnosis.
  • Secondary diagnosis.
• Change in Case Mix Index

5. Works with coding staff to clarify documentation issues by meeting with the coding staff on a regular basis to ensure understanding of documentation requirements.

• Feedback from coding staff

6. Maintains collaborative relationship with staff nurses, care coordinators, utilization review staff, inpatient coding staff and all hospital and health System personnel.

• Feedback from staff.
• Supervisor observation.

7. Provide education/training to physicians, physician office staff, nurses and coders in a variety of settings: One on one; Group presentations and Quick sessions during rounds.

• Presentation skills.
• Presentation materials.
• Evaluations from participants.

8. Works in partnership with physicians, care coordinators, utilization management, staff nurses and Coding Specialists to ensure the medical record accurately reflects patient acuity for quality reporting and case mix index.

Schedule:

Mon - Fri, daytime business hours

Job Description:

Job Requirements

Education

• Successful completion of annual mandatory education requirements.
• Graduate of an accredited school of nursing required.
• Bachelor of Science in Nursing (BSN) preferred.

Experience

• Five years clinical experience in medical surgical nursing and/or inpatient clinical ICD-9 coding with strong computer skills to include Word and Excel, use of laptops, and internet.

License/Certifications

• Current valid Registered Nurse (RN) license, valid compact multistate license, or a temporary permit while awaiting licensure required.

Skills/Knowledge/Abilities

• Excellent communication skills; verbal, written and strong teaching skills, critical thinking skills and knowledge of healthcare delivery system.
• Demonstrates ability to maintain favorable relationships with physicians and Health System personnel.
• Is a self starter and ab