Employment Type : Full-Time
Facilitates improvement in the quality and completeness of patient records on a concurrent basis, using a multi-disciplinary process. Applies clinical knowledge and coding knowledge to evaluate clinical indicators, diagnoses, and treatment plan for assigned inpatients, to identify gaps in physician documentation Required__ Behaviors: Required Qualifications: ** Registered Nurse - Minimum of 3 years strong clinical background in acute care. Current NM Licensure Excellent written and verbal communication skills Analytical thinking skills Team-oriented Basic computer skills Highly-organized Preferred Qualifications: ** BSN Certified Clinical Documentation Specialist (CCDS) Coding experience Duties and Responsibilities**: 1. Comprehensively reviews patient records, concurrently and retrospectively, to assure a complete and accurate representation of the severity of illness and use of resources. 2. Assigns Working DRG 3. Works closely with physicians, Case Management staff, and Coding to review documentation coding practices analyzing whether documentation supports the acuity of the patients. 4. Identifies gaps in physician documentation and facilitates appropriate documentation improvement interventions with physicians. 5. Identifies Clinical Documentation Improvement (CDI) best practices, benchmarks and improvement strategies to augment compliance objectives. 6. Stays current on information pertaining to coding, compliance, clinical guidelines and payer requirements as it relates to MSDRG assignment, documentation and other payment requirements. 7. Each employee is responsible for implementing SJRMC’s Service Standards into their daily work. Safety, Courtesy, Effectiveness, and Stewardship 8. Other duties as assigned Physical Demands and Environmental Work Conditions**: Sensory Requirements: The employee will need to be able to hear: The employee will need to be able to see: San Juan Regional Medical Center provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws. This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation and training. Job Type: Full-time Benefits: Physical Setting: Schedule: Ability to commute/relocate: Experience: License/Certification: Work Location: One location