RN Inpatient Clinical Documentation Specialist, Winston Salem Main Campus

JOB SUMMARY:

This clinical position applies nursing knowledge of documentation requirements to improve the overall quality and completeness of the patient record on a concurrent basis using a multidisciplinary team process. Collaboration with various departments including inpatient coding, quality and analytics, case management, and medical providers to ensure that the information within the patient record is accurate, complete and compliant. This includes documentation to support the severity of illness, expected risk of mortality, hospital acquired conditions, core measures, and patient safety indicators. Education of the patient care team both formally and informally regarding documentation guidelines, coding requirements, and service specific requirements.

EDUCATION/EXPERIENCE:

Bachelor’s degree in nursing and 5-years of direct clinical nursing experience. Recent medical, surgical, or critical care experience preferred. Master's degree preferred.

LICENSURE, CERTIFICATION, and/or REGISTRATION:

Current licensure to practice as a Registered Nurse in the State of North Carolina or compact state licensure. Professional certification in Clinical Documentation (CCDS) highly recommended within 2 years.

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  TMJ

To apply for this position, please click on the "Apply Now" button on this page. You must complete the application process and then submit your application by clicking on the "Submit" button located at the bottom of the page titled "Submit Online Application". You will receive the following message once you hit the submit button: "You have successfully submitted your job application".

Computers are available for applying within the lobby of the Human Resources Department located at 1920 West First Street, (on the corner of Miller and First Street) Winston-Salem, North Carolina 27104. You may also call our office for assistance at (336) 716-6464. Office hours are Monday-Friday, 8:00am-5:00pm.

If you are an individual with a disability and need reasonable accommodation to participate in the application process, please contact our Supervisor of Office Services by phone (336) 716-3367 or email at accommodationrequest@wakehealth.edu.

It is the policy of Wake Forest Baptist Medical Center to administer all educational and employment activities without discrimination because of race, sex, age, religion, national origin, disability, sexual orientation, gender identity or veteran status (except where sex is a bona fide occupational qualification or a statutory requirement) in accordance with all local, state, national laws, executive orders, regulations, and guidelines.

ESSENTIAL FUNCTIONS:

• Concurrent Medical Record Review: Facilitates appropriate clinical documentation to support the severity of illness and complexity of care rendered to all patients. Follows CDE processes for conducting medical record reviews, assigning a working MS-DRG using coding guidelines and querying physicians on a concurrent basis to ensure appropriate documentation in the medical record prior to coding and billing. Consistently meets established productivity targets for record review.

• Post-discharge Medical Record Review: Works collaboratively with inpatient coding staff to identify any missed opportunities related to clinical documentation before case is billed. Prompt and professional interactions are used to effectively resolve any deficiencies. Follows CDE procedures for moving medical records through pre-bill process in a timely manner.

• Collaboration/Communication: Collaborates with case managers, nursing staff, physicians and APP to resolve documentation deficiencies prior to patient discharge. Communicates information effectively by responding to questions, concerns and requests promptly. Encourages communication by promoting open dialogue.

• Education: Provides one-on-one and group education to physicians, advanced practice providers and other key healthcare providers regarding the need for accurate, specific and complete clinical documentation in the patient’s medical record. Support ICD-10-CM/PCS training for providers by reinforcing coding conventions and guidelines.

• Competency: Demonstrates knowledge of documentation requirements and guidelines that recognize DRG payor issues and improves the overall quality and completeness of clinical documentation. Maintains awareness of and works to facilitate optimal outcomes in the CDMP performance and compliance goals. Analyzes clinical status of patients, current treatment plan and past medical history and identifies potential gaps in provider documentation. Participates in departmental quality assurance activities.

• Professional Growth and Development: Demonstrates responsibility for personal development by participating in continuing education offerings. Maintains competence related to MS-DRG assignment, documentation requirements, ICD-10-CM/PCS code assignment and coding guidelines.

• Quality: Participates in clinical documentation compliance activities including identifying hospital acquired conditions and patient safety indicators, by assuring accurate documentation resulting in the most appropriate MS-DRG assignment as well as severity of illness and risk of mortality.

• Technology: Utilizes multiple software systems to collect and ensure the effectiveness of the data. Maintains integrity of data collection by ensuring accurate data entry. Demonstrates competence in navigation of software. Utilizes software as a resource in ensuring accurate documentation.

• Age Specific Competency: Supports the provision of developmentally appropriate patient care in accordance with age specific guidelines for the groups served. Knowledge of physical, motor/sensory, mental, psychosocial, safety and developmental factors in the Age-Specific Care Guidelines as reflected in the patient medical records and interactions with the multidisciplinary team.

SKILLS & QUALIFICATIONS:

• Ability to accept and incorporate critical comment
• Capable of critical thinking, reasoning, deduction and inference while displaying the ability to draw accurate conclusions
• Well organized and detail oriented
• Needs to be self-motivated, self-directed and able to work independently with minimal supervision
• Knowledge of Excel, Microsoft Word and Microsoft Outlook
• Strong interpersonal, communication (verbal, non-verbal and listening) skills
• Experience in developing and presenting education programs
• Competent computer skills including navigation of word processing, spreadsheets and presentation software
• Analytical skills
• Works in a continually changing work environment
• Able to work in a collaborative atmosphere

WORK ENVIRONMENT:

• Subject to irregular hours
• Subject to many interruptions
• May be exposed to infectious and contagious diseases
• Subject to sitting for long periods of time