Clinical RN Documentation Specialist

  • Company: Adecco
  • Posted: November 12, 2016
  • Reference ID: 705830174
Clinical RN Documentation Specialist - St Joseph Hospital Medical Center
For those who want to invent the future of health care, here's your opportunity. We're going beyond basic care to health programs integrated across the entire continuum of care. Join us and help people live healthier lives while doing your life's best work.

The Clinical Document Improvement Specialist - (CDS) is responsible for providing the CDI program day to day CDI implementation of processes related to the concurrent review of the clinical documentation in the inpatient medical record of Optum 360 clients' patients. The goal of the CDS is to assess the technical accuracy, specificity, and completeness of provider clinical documentation, and to ensure that the documentation explicitly identifies all clinical findings and conditions present at the time of service.

This position collaborates with providers and other healthcare team members to make improvements that result in accurate, comprehensive documentation that reflects completely, the clinical treatment, decisions, and diagnoses for the patient. The CDS utilizes clinical expertise and clinical documentation improvement practices as well as facility specific tools for best practice and compliance with the mission/philosophy, standards, goals and core values of Optum 360.
In this position the CDS will be utilizing the Optum™ CDI 3D technology that is assisting hospitals to improve data quality to accurately reflect the quality of care provided and ensure revenue integrity.

Our three-dimensional approach to CDI technology, paired with best-practice adoption methodology and change management support, is helping hospitals make a real impact on CDI efficiency and effectiveness.
• Increase in identification of cases with CDI opportunities, with automated review of 100% of records.
• Improved tracking, transparency and reporting related to CDI impact, revenue capture, trending and compliance.
• Easing the transition to ICD-10 by improving the specificity and completeness of clinical documentation, resulting in more accurate coding.

This position does not have patient care duties, direct patient interactions, nor has no role relative to patient care.

***This will be an office based role at the St Joseph Hospital Medical Center***

Primary Responsibilities:
• Provides expert level review of inpatient clinical records within 24-48 hours of admit; identifies gaps in clinical documentation that need clarification for accurate code assignment to ensure the documentation accurately reflects the severity of the patient condition and acuity of care provided
• Conducts daily follow-up communication with providers regarding existing clarifications to obtain needed documentation specificity
• Provides expert level leadership for overall improvement in clinical documentation by providing proficient level review and assessment, and effectively articulating recommendations for improvement, and the rational for the recommendations
• Actively communicates with providers at all levels, to clarify information and to communicate documentation requirements for appropriate diagnoses based on severity of illness and risk of mortality
• Performs regular rounding with unit-based physicians
• Provides face-to-face educational opportunities with physicians on a daily basis
• Provides complete follow through on all requests for clarification or recommendations for improvement
• Leads the development and execution of physician education strategies resulting in improved clinical documentation
• Provides timely feedback to providers regarding clinical documentation opportunities for improvement and successes
• Ensures effective utilization of the Optum360 Enterprise Computer Assisted Coding (CAC) documenting all clarification activity
• Utilizes only the Optum360 approved forms, whether paper or electronic
• Proactively develops a reciprocal relationship with the Health Information Management (HIM) Coding Professionals
• Coordinate and conducts regular meeting with HIM Coding Professionals to monitor retrospective query rate and address issues
• Engages and consults with Physician Advisor when needed, per the escalation process, to resolve provider issues regarding answering clarifications and participation in the clinical documentation improvement process
• Actively engages with Care Coordination and the Quality Management teams to continually evaluate and spearhead clinical documentation improvement opportunities

Required Qualifications:
• Current Registered Nurse (RN) License
• 3+ years acute care hospital clinical RN experience
• Must be comfortable communicating & working closely with Physicians
• Excellent verbal and written skills including strong organizational skills
• Basic understanding of Microsoft, Word, Excel, PowerPoint and work related software
Preferred Qualifications:
• Previous experience in case management and / or critical care
• Clinical Documentation Improvement experience
• CCDS, CDIP, CCS certification
• BSN degree

Candidates interested in this Opportunity should apply IMMEDIATELY. DO NOT DELAY. Please click on the "Apply Now" button to fill out your application. If you have any questions, you can contact Kristin Kaiser at

***Applicants must be currently authorized to work in the United States on a full-time basis***

This position is being recruited for by Adecco's Service Delivery Center, not your local Adecco Branch Office. To be considered for this position, you must use the "apply now" button to submit your resume. If you have questions about the position, you may contact the recruiter recruiting for this position listed above; however your resume must be received via the "apply now" button included within to be considered.

The Adecco Group is a global leader in HR services. Our group connects over 700,000 associates with our business clients each day through our 6,600 offices in over 70 countries and territories around the world. We offer employment opportunities at any stage in your professional career. Contact us today to discuss available contract and direct hire positions. Adecco Group offers benefits including Holiday, 401(k), Insurance Benefit Plans and Service/Anniversary Bonus opportunities.

Equal Opportunity Employer Minorities/Women/Veterans/Disabled

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