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Position Summary:
Responsible for improving the overall quality and completeness of clinical documentation. Facilitates modifications to clinical documentation through extensive interactions with physicians, nursing staff, other members of the health care team and Health Information Management (HIM) coding staff to ensure that appropriate reimbursement and clinical severity is captured for the level of service rendered to all patients with a DRG based payer.
Job Requirement
Education/Experience:
Option 1: Graduation from an accredited school of nursing and three (3) years of clinical nursing experience and three (3) years clinical documentation improvement experience.
Option 2: Physician graduate International MD with three (3) years of acute care experience and three (3) years Clinical Documentation Improvement (CDI) experience.
Option 3: Equivalent to a Bachelor's degree in Healthcare and three (3) years Health Information Management in an acute care hospital inpatient experience and three (3) years Clinical Documentation Improvement (CDI) experience.
Licensing/Certification Requirements:
Option 1: Valid license by the State of Nevada to practice as a Registered Nurse and one of the following, Certified Clinical Documentation Specialist (CCDS), Certified Clinical Documentation Specialist-Outpatient (CCDS-O) or Certified Document Improvement Practitioner (CDIP).
Option 2: An international medical graduate degree and one of the following: Certified Document Improvement Practitioner (CDIP), Certified Clinical Documentation Specialist (CCDS), Certified Clinical Documentation Specialist-Outpatient (CCDS-O).
Option 3: Certification in one of the following: Certified Coding Specialist (CCS), Registered Health Information Technician (RHIT), or Registered Health Information Administrator (RHIA), issued by the American Health Information Management Association, Certified Professional Coder (CPC), Certified Professional Coder-Physician-based (CPC-P), AND one of the following: Certified Document Improvement Practitioner (CDIP), Certified Clinical Documentation Specialist (CCDS), Certified Clinical Documentation Specialist-Outpatient (CCDS-O).
Knowledge, Skills, Abilities, and Physical Requirements
Knowledge of:
Medicare reimbursement system and coding structures; hospital policies and procedures; Joint Commission Accredited Health care Organizations standards, state statutes governing hospital services and health care, Medicare/Medicaid guidelines and other relevant regulations and standards; clinical medical and nursing procedures; disease processes; department and hospital safety practices and principles; patient rights; age specific patient care practices; infection control policies and practices; department and hospital emergency response policies and procedures.
Skill in:
Working effectively under pressure; holding in complete confidence all information acquired from medical records and physicians; interpreting patient charts to determine whether care given was appropriate and properly documented; interpreting regulations and standards for others; writing reports, meeting minutes and other technical documents; analyzing statistical and other quantitative data; critical thinking; conflict management; dealing with departmental issues involving self or other employees in professional, forthright and impartial manner; applying investigative and interviewing techniques; using a computer and a variety of software applications; communicating with a wide variety and establishing interpersonal relationships to interact effectively with co-workers, supervisor, staff in other work units and exchange or convey information.
Physical Requirements and Working Conditions:
Mobility to work in a typical office setting and use standard equipment, stamina to remain seated for extended periods of time, vision to read printed materials and a VDT screen, and hearing and speech to communicate effectively in person and over the telephone. Strength and agility to exert up to 10 pounds of force occasionally and/or an eligible amount of force frequently or constantly to lift, carry, push, pull or otherwise move objects. May work shifts and weekends.
Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of this classification.
