RN Specialist, Clinical Documentation

About This Role

This mission-driven role involves performing concurrent and retrospective reviews of patient records to ensure accuracy, specificity, and compliance in clinical documentation. The specialist educates providers on documentation practices and collaborates with various departments to achieve accurate patient records and billing. The role requires continuous education on coding guidelines, clinical medicine, and regulatory policies.

Responsibilities

• Perform concurrent and/or retrospective review of designated inpatient, outpatient, and ambulatory patient records to assess for accuracy, specificity, and compliance of patient status, charges, and billing
• Review and appeal clinical denials in accordance with current medical literature, CMS regulations, and individual payer contracts, policies, or provider manuals
• Consolidate trends and track outcomes for routine Revenue Cycle reporting
• Escalate findings to Revenue Cycle leadership
• Educate providers, coding, CDI, UM, Revenue Cycle, and other ancillary departments regarding documentation accuracy, specificity, and compliance with rules and regulations
• Work collaboratively with clinical and non-clinical departments across the organization to support process improvement and obtaining accurate and compliant billing practices

Requirements

• Associate's Degree
• 6 years of experience as a nurse in a hospital environment
• 3 of the 6 years with appropriate level of experience in one or a combination of the following medical documentation related functions: clinical coding, case management, DRG coordination, physician education, Medicaid/Medicare reimbursement
• RN-Registered Nurse - DORA - Department of Regulatory Agencies
• Demonstrate knowledge of the pathophysiology of the disease process
• Demonstrate clinical expertise in areas of urgent/emergent, medical/surgical, obstetrical, pediatric, and ambulatory care
• Communicate and interact tactfully with physicians and other professionals by expressing ideas clearly and concisely and addressing audiences effectively
• Ability to read and interpret professional journals, financial reports, and legal documents as necessary
• Ability to define problems, collect and summarize data, establish facts and draw conclusions
• Possess knowledge of clinical documentation and coding concepts, DRG assignments, Inpatient Prospective Payment System (IPPS) and CMS rules and regulations
• Demonstrate knowledge including but not limited to, value-based purchasing, bundled payments, accountable care organizations and readmission reduction program
• Microsoft Office Excel and SharePoint
• Variety of documentation and coding programs

Benefits