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RN Clinical Documentation Improvement Specialist

Location
Manchester, NH

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Description
Job Details :
Under the general direction of the Director of Revenue Cycle and within established policies and procedures, the incumbent performs the following functions : Reviews clinical documentation on inpatient admissions to identify opportunities to improve provider documentation to ensure accurate and complete coding, severity of illness and / or risk of mortality.
Reviews records that may have documentation improvement opportunities and query and / or directly communicate with the physicians and providers to obtain the necessary documentation.
Follows up on all cases queried until an acceptable response is received. Maintains knowledge of documentation requirements in accordance with AHA Coding Clinic, Core Measures specifications and external rating methodologies.
Maintains knowledge of all outside grading company standards and guidelines and how documentation affects hospital ratings.
Query physicians when necessary for complete documentation of these issues to better identify the severity of illness and risk of mortality.
Educates medical staff on all documentation guidelines for coding and external healthcare rating companies about the effects on reimbursement, severity of illness and risk of mortality.
Tracks all responses of queries and utilize reporting techniques for statistical purposes. Report and track all activities and outcomes of queries.
Tracks all trends found for further education to the providers and the coding staff. Develops and initiates educational programs regarding proper documentation.
Interfaces with the Coding, Case Management and Performance Improvement staff as necessary. Tracks Joint Commission as needed concurrently and prompt providers for required documentation.
Conducts performance improvement activities and special projects as needed. Enters working DRG and codes into CDI software (3M 360).
Maintains established polices and procedures, objectives, quality assessment and safety standards. Provides outstanding services to all customers, fosters teamwork;
and practices fiscal responsibility through improvement and innovation. QUALIFICATIONS : Education :
RN, BSN preferred. Experience :
At least 5 years of acute care hospital experience with a strong clinical knowledge.
Must have excellent communication skills and the ability to work independently.
Excel and Word experience required. Licensure / Certification :
Current license in the State of New Hampshire as a Registered Nurse

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