FILLEDRN Clinical Documentation Specialist

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Within Banner Health Corporate, you will have the opportunity to apply your unique experience and expertise in support of a nationally-recognized healthcare leader. We offer stimulating and rewarding careers in a wide array of disciplines. Whether your background is in Human Resources, Finance, Information Technology, Legal, Managed Care Programs or Public Relations, you'll find many options for contributing to our award-winning patient care.

POSITION SUMMARY
This position is responsible for reviewing content of the medical record and assisting in the clarification of any documentation ambiguities noted. This position is a member of the clinical team and acts as a consultant/subject matter expert to facility staff and Providers related to medical record clinical documentation requirement to ensure the overall completeness, compliance and specificity of Provider documentation exists. This position is responsible for identifying and capturing additional revenue opportunities and will also be the documentation liaison for the facility between acute care coding and Providers.

CORE FUNCTIONS
1. Provides subject matter expertise related to DRG, clinical documentation opportunities and requirements. Serves as an essential member of the clinical team, emphasizing their role in reviewing content of the medical record, assisting in the clarification of documentation ambiguities. Serves as the liaison between acute care coding and Providers to explain, educate and assist in the needed documentation requirements to accurate conversion from the "clinical language" to the needed "coding language" in order to capture revenue.

2. Conducts accurate and timely concurrent record reviews, recognizing opportunities for documentation improvement through specialized training and software. Utilizes available resources to formulate clinically credible "documentation clarification questions" for members of the clinical team aimed at improving the accuracy of the documentation process which is followed by effective and appropriate communication with Providers and timely follow up on all cases.

3. Ensures data integrity of the clinical documentation database through compliant, accurate and appropriate entries, which include but is not limited to, accurate input of case data, correct assignment of documentation clarification types and Provider responses, and ensuring precise case reconciliation with correct DRG shifts recorded.

4. Ensures the accuracy and completeness of clinical information used for measuring and reporting Provider and facility outcomes (coding assignments, HAC, quality of care, facility and system initiatives) while facilitating HIMS dept compliance of time requirements for coding and billing revenue cycle.

5. Educates customers through presentations and/or reports for clinicians and facility management on clinical documentation opportunities, acute care coding and reimbursement issues, as well as performance improvement methodologies.

6. Serves as member of facility task force meetings, and as requested attends facility steering committee meetings and/or other facility meetings.

7. This position works independently in a "hybrid" work mode - working both in-facility as well as remotely and has multi-facility/entity responsibility, with no direct budgetary oversight. This position is a member of the clinical team ensuring accuracy and compliance with acute care coding assignments, POA status, HAC, quality of care, supports specific Hospital and System initiatives, and aids HIMS Dept in meeting their time requirement of the coding and billing revenue cycle. Extensive interaction with Providers, HIMS professionals, nursing and other ancillary staff. Internal Interactions: All levels of nursing management and staff, medical staff, Providers and all other members of the interdisciplinary health care team. External Interactions: Physicians and their office staff.



MINIMUM QUALIFICATIONS
Must possess a strong knowledge of clinical care as normally obtained through the completion of a bachelor's degree in nursing.

Requires Registered Nurse (R.N.) license in state worked.

Requires two to four years of recent acute care experience either in a Hospital or Surgical setting. Must have the ability to interface with multiple software applications, work independently, possess demonstrated critical thinking skills, problem-solving abilities, communication and time management skills. Must demonstrate ability to work effectively in an interdisciplinary team format.

PREFERRED QUALIFICATIONS
Experience with acute clinical documentation programs or coding. Certified Clinical Documentation Specialist, Certified Coding Specialist credential.

Additional related education and/or experience preferred.