Requisition ID: 44164
Location: Presence St Mary Kankakee
500 West Court Street, Kankakee, IL 60901-3661 United States (US)
Daily Hours: 8
Standard Hours: 40
Employment Status: Full-time
Employment Type: Regular
The Clinical Documentation Integrity Specialist (CDIS) - Registered Nurse ensures the overall quality and completeness of medical record clinical documentation. Facilitates modifications to clinical documentation through concurrent interaction with physicians, nursing staff, other patient caregivers, and health information coding staff to guarantee appropriate reimbursement and clinical severity is captured for the level of service rendered to all inpatients. Ensures timely, accurate and complete documentation of clinical information is used for measuring and reporting physician and hospital outcomes. Educates all members of the patient care team regarding documentation issues on an ongoing basis.
ESSENTIAL DUTIES AND RESPONSIBILITIES
- Facilitates concurrent modifications to clinical documentation supporting compliant and accurate documentation of medical conditions being monitored and treated during the inpatient stay
- Demonstrates knowledge of DRG payer issues, documentation opportunities and coding guidelines.
- Communicates with the individual physicians and medical staff to facilitate complete and accurate documentation of the inpatient record
- Improves the overall quality and completeness of clinical documentation through daily review of medical records and ensures accuracy and completeness of clinical documentation used for measuring and reporting physician and hospital outcomes.
- Conducts follow up reviews of clinical documentation to ensure points of clarification have been recorded in the patient's chart. Reviews clinical issues with coding staff and nurses to ensure appropriate inpatient technical diagnosis and procedural coding.
- Educates internal customers, including physicians, nurses and other members of the healthcare team regarding clinical documentation opportunities, coding and reimbursement issues, as well as performance improvement methodologies.
- Is accountable for gathering and analyzing information pertinent to the documentation process, findings and outcomes in compliance with coding and regulatory guidelines
- Maintains thorough and current knowledge of clinical care and treatment of assigned patient populations to critically assess appropriateness of documentation
Education and/or Experience
RN required; BSN preferred. Minimum of 5 years inpatient clinical experience. Advanced clinical expertise and extensive knowledge of complex disease processes with broad clinical experience in an inpatient setting is preferred.
Certificates, Licenses, Registrations
Registered Nurse with a current Illinois License required.
Business Unit: Corporate (LRHC and LPH)
EOE of Minorities/Females/Vets/Disability