RN Clinical Documentation Specialist - Clinical Data Management (Galveston) - 66422
Company: University of Texas Medical Branch
Posted on: March 19, 2020
REQUIRED EDUCATION / EXPERIENCE:
--- RN or MD. 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. With expectation of obtaining CCDS or CDIP within 2.5
--- OR: RHIA/RHIT/CCS with five years inpatient coding experience
and documented education in anatomy/physiology and pharmacology.
With expectation of obtaining CCDS or CDIP within 2.5 years.
--- Licensure/Certification: Currently licensed as a Registered
Nurse or CCS
JOB SUMMARY: Responsible for the overall improvement of the quality
and accuracy of medical record documentation through interaction
with physicians, members of the patient care team and hospital
coding staff. Ensures clinical documentation accurately reflects
the appropriate level of service provided, severity of illness, and
risk of mortality of each patient. Successfully facilitates the
accurate representation of patient status that translates into
The salary range for this position is from $61,600/yr - $92,400/yr,
commensurate with experience.
This position is a pay Band Code CS22
Specific Job Related Duties
--- Concurrently review inpatient admissions to identify
opportunities to clarify missing or incomplete documentation.
--- Collaborate with providers, case managers, coders, and other
healthcare team members to facilitate comprehensive health record
documentation that reflects clinical treatment, decisions,
diagnoses, and interventions.
--- Understand the general flow of health information from medical
record documentation and discharge, through coding, to billing and
finally to data reporting.
--- Utilize the hospital's designated clinical documentation system
to conduct reviews of the health record and identify opportunities
--- Apply knowledge of inpatient ICD-9 & 10 coding guidelines and
clinical documentation requirements to assign working MS-DRG.
--- Enter review information and working MS-DRG/APR-DRG's with
associated length of stay in 3M shared information system and
updates this information as needed to reflect any changes in
patient's status, procedures and treatments.
--- Communicate with providers either through discussion or in
writing (e.g., formal queries) regarding missing, unclear, or
conflicting health record documentation for clarification.
--- Conduct follow-up of posted queries to ensure queries have been
answered and physician responses have been appropriately
--- Educate and communicate clinical documentation opportunities in
the appropriate hospital venues for staff and physician learning
--- Act as a consultant to coding professionals when additional
information or documentation is needed to assign coded data.
--- Collaborate with HIM/coding professionals to review individual
problematic cases and ensure accuracy of final coded data in
conjunction with CDI managers, coding managers, and/or physician
--- Assume responsibility for professional development by
participating in workshops, conferences and/ or in-services.
--- Keep current with changes in coding guidelines, compliance,
reimbursement, and other relevant regulatory updates.
--- Demonstrate excellent observation skills, analytical thinking
and problem solving plus good verbal and written communication.
--- Contribute to a positive working environment and perform other
duties as assigned or directed to enhance the overall efforts of
--- Maintain positive and open communication with physicians,
members of the patient care team, case management and hospital
--- Adhere to internal controls and reporting structure.
--- Comply with all relevant policies, procedures, guidelines and
other regulatory, compliance and accreditation standards.
RN with RHIA/RHIT, CCS or CCDS; 5 years experience in acute care
(Med-Surg) inpatient hospital setting performing coding or clinical
#Top #Nurse #Prof #audit
Equal Employment Opportunity
UTMB Health strives to provide equal opportunity employment without
regard to race, color, national origin, sex, age, religion,
disability, sexual orientation, gender identity or expression,
genetic information or veteran status. As a VEVRAA Federal
Contractor, UTMB Health takes affirmative action to hire and
advance women, minorities, protected veterans and individuals with
Req id: 66422
Keywords: University of Texas Medical Branch, Galveston , RN Clinical Documentation Specialist - Clinical Data Management (Galveston) - 66422, Executive , Galveston, Texas
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