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Job Description

CLINICAL DOCUMENTATION SPECIALIST RN
Date: 02/03/2010
Location: Chicago, IL
Facility:TRINITY HOSPITAL
CLINICAL DOCUMENTATION SPECIALIST RN - 30477 		Apply Now
Current RN license in the State of Illinois and 2-3 years relevant clinical experience and knowledge of ICD-9 coding classification system and DRG's. 2-3 Case management experience preferred.

• Global perspective of changing health care environment

• Ability to prioritize work

• Basic computer skills

• Effective problem-solver with good interpersonal communication skills, verbal and written

• Effective observation, analytical, and critical thinking skills.

Job Description:

1. Improves the overall quality and completeness of clinical documentation by performing admission/continued stay reviews for specific patient population using documentation guidelines.

2. Confers with physicians, face to face or via question sheet, to clarify information, obtain needed documentation, present opportunities and educate for appropriate DRG, based on Severity of Illness.

3. Conducts follow up reviews of clinical documentation to ensure points clarified with the physician have been recorded in the patient’s chart.

4. Concurrently confers with coding specialists to ensure appropriate DRG assignment, and completeness of supporting documentation.

5. Reviews clinical issues with the coding staff to assign a working DRG.

6. Demonstrates knowledge of DRG payer issues and documentation requirements,

opportunities and strategies.

7. Verifies patient status in Allegra against physician orders to ensure consistency.

1. Identifies and works with and through others to eliminate system barriers to achieving stated goals.

2. Compiles department statistics according to department policy.

3. Participates in Quality Monitoring Activities per departmental policy.

4. Maintains positive open communication with physicians, interdisciplinary care team members and Department Director.

1. Educates all internal customers on clinical documentation opportunities, coding and reimbursement issues.

2. Develops and conducts ongoing education for new staff, including new clinical documentation specialists, case managers, coders, physicians, nursing and allied health professionals.

3. Keeps abreast of current standards of care/standards of regulatory bodies, coding, and DRG changes.

4. Participates in activities to enhance professional growth and development by involvement in professional organizations and continuing education.
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