Description: Our client is currently seeking a Clinical Documentation Specialist RN!
Job Details: Temp to Hire
Location: Fully remote
Hours: Monday-Friday 8AM-5PM CST
Compensation: $48.08/hour
This job will have the following responsibilities:
Completes reviews of patient records for assigned patient population to: (a) independently evaluate documentation to assign the principal diagnosis, pertinent secondary diagnoses, and procedures for accurate MS-DRG or APR-DRG assignment in compliance with coding guidelines and regulatory requirements; and (b) Conducts follow-up reviews of patients to support and assign a working or final MS-DRG or APR-DRG assignment.
Contributes to accuracy of Hospital Value-Based Purchasing (VBP) results, how patients are included in the Potentially Preventable Readmissions (PPR), and to identify those conditions that may be Hospital Acquired Conditions (HAC), Patient Safety Indicators (PSI), accuracy of Present on Admission (POA) conditions, and penalties will be associated with lack of proper documentation.
Drafts and submits compliant queries to providers in compliance with industry compliance standards; conducts follow up reviews of clinical documentation to ensure points of clarification with providers have been accurately recorded in the patient's medical record.
Ability to reconcile reviewed cases with final coding and communication with coders to identify root cause of CDI-Coder final DRG mismatch and resolution of incongruence as part of ongoing quality control efforts.
Meets and exceeds established productivity guidelines as well as additional key performance indicators such as review rates, query rates, agreement rates, etc.
Validates documented clinical conditions in the medical record.
Follows queries through to completion.
Contributes to development of new caregivers.
Maintains flexibility in work assignments based on organizational business need.
Stays current with AHA Official Coding and Reporting Guidelines, CMS and other agency directives for ICD-10-CM coding. Attends any required CDI and/or coding education as assigned.
Utilizes the enterprise standard CDI tool set and follows standard process and procedures. Employs a continuous improvement mindset by identifying and communicating opportunities in the development of new and/or changes to standard processes and tools.
Able to breakdown raw information and undefined problems into specific workable components that in-turn clearly identifies the issues at hand. Makes logical conclusions utilizing independent judgment and discretion, anticipates obstacles and considers different approaches that are relevant to the decision-making process.
Identifies and acts upon opportunities. Motivates others during times of organizational stress, ambiguity, and change. Creates an environment that encourages prudent risk-taking, sharing of best practices, and alerting groups to alternative approaches.
Consistently displays awareness and sensitivity to the needs of internal and/or external clients. Escalates unmet client needs to the CDI Core Leader for awareness and action as appropriate.
Communicates ideas or positions in a persuasive manner that builds support, agreement, or commitment.
Takes actions that directly or indirectly influence others to create buy-in, gain trust, and motivate actions in others or win concessions without damaging relationships.
Voluntarily takes the first steps to identify and address existing and potential obstacles, issues, and opportunities.
Innovation: Improves organizational performance through the application of original thinking to existing and emerging methods, processes, products and services. Employs sound judgment in determining how innovations can be deployed to produce return on investment.
Anticipates, identifies and defines problems. Seeks root causes. Develops and implements practical and timely solutions.
Qualifications & Requirements:
Registered Nurse Required.
Bachelors' Degree
Maintains a high degree of professionalism.
Possesses flexibility to work in a fast-paced and dynamic environment.
All qualified and interested candidates, please send your most updated resumes to edemey@judge.com for immediate consideration!
Contact: edemey@judge.com
This job and many more are available through The Judge Group. Find us on the web at www.judge.com
