Position Summary:

The Clinical Documentation Coordinator RN is a professional member of the health care team who has a broad clinical knowledge base and understanding of DRG documentation requirements. The ‘s primary purpose is to facilitate improvement in the overall quality, completeness, and compliance of clinical documentation in the medical record. The facilitates clarification of clinical documentation through extensive medical record review, interaction with physicians, nursing staff, and other members of the patient care team utilizing coding and clinical documentation expertise.

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Duties & Responsibilities:

Demonstrates knowledge of MS-DRGs, documentation requirements and guidelines.. Identifies patients to be reviewed based on specific criteria related to diagnosis, clinical condition, cost and/or payer. Performs thorough chart reviews to identify co-morbidities/complications. Collaborates with coders to ensure documentation of all known CCs or Major CCs (MCC) on the DRG Coding Abstract. Facilitates clarification of clinical documentation to ensure complete and compliant documentation that reflects the level of service rendered and medical necessity. Confers with and/or queries attending physicians on a concurrent basis regarding incomplete or vague documentation. Facilitates physicians to document all CCs which may effect the assignment of DRGs. Conducts follow up reviews of clinical documentation to ensure that points of clarification have been documented in the medical record prior to final coding and billing. Reviews clinical issues with the coding staff including working with the coding staff to clarify documentation and identify missed opportunities related to clinical documentation and coding guidelines. Validates that medical documentation supports final coding. Utilizes the DocMS software program for documentation of reviews. Monitors patients progress throughout an episode of care for LOS, based on acuity and regulatory/legislative requirements. Liaisons with the Physician Advisor regarding complex cases and established protocols. Coordinates and collaborates in regular meetings with key members of the Clinical Documentation team to develop and implement strategies for improvement of clinical documentation and financial outcomes. Completes monthly reports and submits in a timely manner. Participates in data collection and analysis to identify opportunities for performance improvement related to the operational processes of the Clinical Documentation Program. Participates in resource management projects and Utilization Management Committee as assigned. Informs patient/family/proxy/guardian of healthcare benefits/coverage as needed including Medicare appeal rights as applicable. Maintains readiness and participates in JHS JCAHO activities. Performs MMF/SNEC duties and other hurricane/disaster related activities as assigned. Participates in nursing and service excellence activities. Follows and performs all related unit specific policies and procedures, as detailed on the unit specific competency check-list. Utilizes job and unit specific equipment as required. Demonstrates behaviors of service excellence and CARE values (Compassion, Accountability, Respect and Expertise). Performs all other related job duties as assigned.

Experience:

Generally requires 3 to 5 years of related experience. CDI experience preferred.

Education:

BSN or Bachelor’s degree in related field is required. Master’s degree is preferred.

License Certification:

Valid Florida RN license is required. American Heart Association Basic Life Support (BLS) and any additional applicable life support certification for Healthcare Providers is required upon hire with at least 6 months validity and maintenance at JHS for the duration of employment. Must meet and maintain valid and current all unit specific and organizational skills/competencies, certifications/licensures, as required by regulatory and/or nursing standard of practice for the specialty.

Knowledge Skill Abilities:

General Competencies: Ability to analyze, organize and prioritize work accurately while meeting multiple deadlines. Ability to communicate effectively in both oral and written form. Ability to handle difficult and stressful situations with professional composure. Ability to understand and follow instructions. Ability to exercise sound and independent judgment. Knowledge and skill in use of job appropriate technology and software applications. Management Competencies: Knowledge of business and management principles involved in strategic planning, resource allocation, human resources modeling, leadership technique, production methods, and coordination of people and resources. Skill in monitoring/assessing the performance to make improvements or take corrective action. Skill in using logic and reasoning to identify the strengths and weaknesses of alternative solutions, conclusions, or approaches to problems. Ability to plan, implement, and evaluate programs. Ability to establish goals and objectives. Ability to recognize, analyze, and solve a variety of problems. Nursing Competencies: Ability to understand, respects and accommodates patients preferences and needs with regards to their individual beliefs, customs and practices. Must have ability to clearly, accurately and effectively provide information to doctors, other nurses, patients, and family members. Must have ability to show compassion, patience and maintain non-judgmental approach to patients, their families as well as other employees and customers. Unit Specific: Must have clinical knowledge, skill and ability to fully and accurately complete all required unit competencies, as indicated in the unit competency check-list. Knowledge of business and management principles involved in strategic planning, resource allocation, human resources modeling, leadership technique, production methods, and coordination of people and resources. Skill in monitoring/assessing the performance to make improvements or take corrective action. Skill in using logic and reasoning to identify the strengths and weaknesses of alternative solutions, conclusions, or approaches to problems. Ability to plan, implement, and evaluate programs. Ability to establish goals and objectives. Ability to recognize, analyze, and solve a variety of problems.

Physical Demands:

Job function requires extended standing or walking. Must be able to carry objects weighing 21 to 50 pounds. Able to lift or move objects weighing 51 to 100 pounds with the use of appropriate devices. Jobs in this group require frequent visual acuity to perform activities related to extended use of computers. Additional information and provision requests for reasonable accommodation will be provided by the home unit/department in collaboration with the Reasonable Accommodations Committee (RAC).

Work Environment:

Jobs in this group are required to function in a fast paced environment with occasional high pressure or emergent and stressful situations. Frequent interaction with a diverse population including team members, providers, patients, insurance companies and other members of the public. Function is subject to inside environmental conditions, with occasional outdoor exposures. Exposure to various environments such as: communicable diseases, toxic substances, medicinal preparations and other conditions common to a hospital and medical office environment. May also be exposed to needle sticks, airborne infections, medical gases, X-Ray, chemical exposures and other potential hazards. Must wear Personal Protective Equipment (PPE) when exposed to infectious/clinical hospital environment. Reasonable accommodations can be made to enable people with disabilities to perform the described essential functions. Additional information and provision requests for reasonable accommodation will be provided by the home unit/department in collaboration with the Reasonable Accommodations Committee (RAC).

Clinical Documentation Coordinator, RN Remote (Florida Resident Only) in Florida ID-7978