Clinical Documentation Specialist
Best Care
1 hour ago
Full-time
On-site
Council Bluffs, Iowa, United States
Registered Nurse
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 Jennie Edmundson Hospital
Address: 933 E. Pierce St. - Council Bluffs, IA
Work Schedule: Mon - Fri, daytime business hours
Responsible for concurrent review of clinical documentation for all selected
admissions to ensure an accurate representation of the clinical condition of the
patient through complete and accurate reporting of diagnoses and procedures.
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 ICD-10 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
* Graduate of an accredited school of nursing required.
* Bachelor of Science in Nursing (BSN) preferred.
* Successful completion of annual mandatory education requirements.
Experience
* Five years clinical experience in medical surgical nursing and/or ICU, or
case management, and/or inpatient clinical coding, and/or healthcare revenue
cycle.
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.
* Develops collaborative relationships with a variety of professionals
including physicians.
* Is a self starter and able to deal with resistance and complex situations.
* Ability to foster and attitude of teamwork and trust.
* Functions as an educator and enabler to physicians. Must be objective and
logical.
PHYSICAL REQUIREMENTS
Weight Demands
* Light Work - Exerting up to 20 pounds of force.
Physical Activity
* Not necessary for the position (0%):
* Climbing
* Crawling
* Kneeling
* Occasionally Performed (1%-33%):
* Balancing
* Carrying
* Crouching
* Distinguish colors
* Grasping
* Lifting
* Pulling/Pushing
* Standing
* Stooping/bending
* Twisting
* Walking
* Frequently Performed (34%-66%):
* Keyboarding/typing
* Reaching
* Repetitive Motions
* Sitting
* Speaking/talking
* Constantly Performed (67%-100%):
* Hearing
* Seeing/Visual
Job Hazards
* Not Related:
* Chemical agents (Toxic, Corrosive, Flammable, Latex)
* Physical hazards (noise, temperature, lighting, wet floors, outdoors,
sharps) (more than ordinary office environment)
* Equipment/Machinery/Tools
* Explosives (pressurized gas)
* Electrical Shock/Static
* Radiation Alpha, Beta and Gamma (particles such as X-ray, Cat Scan, Gamma
Knife, etc.)
* Radiation Non-Ionizing (Ultraviolet, visible light, infrared and microwaves
that causes injuries to tissue or thermal or photochemical means)
* Mechanical moving parts/vibrations
* Rare (1-33%):
* Biological agents (primary air born and blood born viruses) (Jobs with
Patient contact) (BBF)
About Methodist:
Nebraska Methodist Health System is made up of four hospitals in Nebraska and
southwest Iowa, more than 30 clinic locations, a nursing and allied health
college, and a medical supply distributorship and central laundry facility. From
the day Methodist Hospital was chartered in 1891, service to our communities has
been a top priority. Financial assistance, health education, outreach to our
diverse communities and populations, and other community benefit activities have
always been central to our mission.
Nebraska Methodist Health System is an Affirmative Action/Equal Opportunity
Employer and does not discriminate on the basis of race, color, religion, sex,
age, national origin, disability, veteran status, sexual orientation, gender
identity, or any other classification protected by Federal, state or local law.
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 Jennie Edmundson Hospital
Address: 933 E. Pierce St. - Council Bluffs, IA
Work Schedule: Mon - Fri, daytime business hours
Responsible for concurrent review of clinical documentation for all selected
admissions to ensure an accurate representation of the clinical condition of the
patient through complete and accurate reporting of diagnoses and procedures.
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 ICD-10 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
* Graduate of an accredited school of nursing required.
* Bachelor of Science in Nursing (BSN) preferred.
* Successful completion of annual mandatory education requirements.
Experience
* Five years clinical experience in medical surgical nursing and/or ICU, or
case management, and/or inpatient clinical coding, and/or healthcare revenue
cycle.
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.
* Develops collaborative relationships with a variety of professionals
including physicians.
* Is a self starter and able to deal with resistance and complex situations.
* Ability to foster and attitude of teamwork and trust.
* Functions as an educator and enabler to physicians. Must be objective and
logical.
PHYSICAL REQUIREMENTS
Weight Demands
* Light Work - Exerting up to 20 pounds of force.
Physical Activity
* Not necessary for the position (0%):
* Climbing
* Crawling
* Kneeling
* Occasionally Performed (1%-33%):
* Balancing
* Carrying
* Crouching
* Distinguish colors
* Grasping
* Lifting
* Pulling/Pushing
* Standing
* Stooping/bending
* Twisting
* Walking
* Frequently Performed (34%-66%):
* Keyboarding/typing
* Reaching
* Repetitive Motions
* Sitting
* Speaking/talking
* Constantly Performed (67%-100%):
* Hearing
* Seeing/Visual
Job Hazards
* Not Related:
* Chemical agents (Toxic, Corrosive, Flammable, Latex)
* Physical hazards (noise, temperature, lighting, wet floors, outdoors,
sharps) (more than ordinary office environment)
* Equipment/Machinery/Tools
* Explosives (pressurized gas)
* Electrical Shock/Static
* Radiation Alpha, Beta and Gamma (particles such as X-ray, Cat Scan, Gamma
Knife, etc.)
* Radiation Non-Ionizing (Ultraviolet, visible light, infrared and microwaves
that causes injuries to tissue or thermal or photochemical means)
* Mechanical moving parts/vibrations
* Rare (1-33%):
* Biological agents (primary air born and blood born viruses) (Jobs with
Patient contact) (BBF)
About Methodist:
Nebraska Methodist Health System is made up of four hospitals in Nebraska and
southwest Iowa, more than 30 clinic locations, a nursing and allied health
college, and a medical supply distributorship and central laundry facility. From
the day Methodist Hospital was chartered in 1891, service to our communities has
been a top priority. Financial assistance, health education, outreach to our
diverse communities and populations, and other community benefit activities have
always been central to our mission.
Nebraska Methodist Health System is an Affirmative Action/Equal Opportunity
Employer and does not discriminate on the basis of race, color, religion, sex,
age, national origin, disability, veteran status, sexual orientation, gender
identity, or any other classification protected by Federal, state or local law.