Clinical Documentation Specialist Rn F/T Day

Overview:
The Manager, Clinical Documentation at JFK Medical Center within the Hackensack Meridian Health (HMH) network interfaces with the Health Information Management (HIM) Department and reports directly to the Clinical Documentation Program (CDP) department vice president. Responsible for the management of the Clinical Documentation Improvement Specialists/RN's and all other direct reports.
Responsibilities:
1. Management of daily operations of the Clinical Documentation Program Department, which includes but is not limited to Case assignments, Case reviews, Quality reviews (Mortality, HAC, PSI), and DRG Discrepancies.
2. Educates physicians through presentations, telephone, electronic and face to face as needed.
3. Interacts with physicians for clarification of diagnoses to ensure the most accurate documentation in the medical record. 4. Support management by insuring team member engagement and general communications.
5. Act as a resource to senior management, medical staff, nursing, administration, quality department, coding compliance specialists, coders and others as you develop and implement each sections goals, objectives and quality monitors to be consistent with the plans and objectives of the Clinical Documentation Department and HMH.
6. Ensure that team is kept current on regulations and procedures and that they have the tools needed to perform their duties at optimal levels and within established time-frames.
7. Monitor quality and outcomes of program through audits, reports and comparison to national standards.
8. Concurrent review of medical records for accurate, concise and consistent documentation of diagnoses for accurate reporting of the severity of illnesses and risks of mortality.
9. Compliance reviews of RAC audits and other insurance auditing companies. 10. Collaborate with the Physician advisor(s) to ensure physicians understand how to interact with the Clinical Documentation Department.
11. Work closely and effectively with Coders, DRG Coordinators, Coding Supervisors and Coding Management.
12. Review monthly performance with Hospitalists group.
13. Education of the RN/Clinical Documentation Improvement Specialists as needed.
14. Develop and maintain updated policies and procedures for the Department.
15. Monitor individual productivity rates for all Clinical Documentation Specialists.
16. Oversee quality of work and if needed, perform the roles of the Clinical Documentation staff.
17. Monitor progress of quality goals through established tracking tools while evaluating and implementing best practices to ensure maximization of the HMH resources.
18. Identify staffing needs and assure coverage for any staff shortages utilizing external and internal resources to maintain process goals.
19. Manage, hire, coach/mentor and develop Clinical Documentation Program team members.
20. Work in conjunction with vice president to prepare and complete team member performance evaluations as part of the annual performance review process.
21. Other duties and/or projects as assigned.
22. Adheres to HMH Organizational competencies and standards of behavior.
Qualifications:
Education, Knowledge, Skills and Abilities Required:
1. Bachelor of Nursing; or Graduate from Medical School with 12+ years of experience reviewing and screening inpatient admissions and observations; or other equivalent experience.
2. Must possess excellent communication, analytical and interpersonal skills.
3. Strong clinical and critical thinking skills.
4. Extensive knowledge of ICD-9 and/or ICD-10 coding and Inpatient Coding.
5. Familiarity with severity of illness, case mix index, risk adjustment coding and risk of mortality indicators.
6. Ability to interact well with physicians and other members of allied health care team, including HIM coders.
7. Must be computer literate, have working knowledge of Google and/or Microsoft applications.
Education, Knowledge, Skills and Abilities Preferred:
1. Advanced practice degree.
2. Registered Nurse (RN) with 5 years recent experience or Physician in med/surg. critical care, intensive care or emergency room care preferred.
3. ICU, CCU, or strong Med/Surg experience.
4. Knowledge of Risk Adjustment Coding, a plus.
Licenses and Certifications Required:
1. NJ State Professional Registered Nurse License or Certified Coding Specialist or Certified Clinical Documentation Specialist or Clincial Documentation Improvement Practitioner.