Job Description

Job Description

Baptist Health System - San Antonio TX is seeking a Registered Nurse (RN) Clinical Document Improvement Specialist Level I for a nursing job in San Antonio, Texas.

• Specialty: Clinical Document Improvement Specialist
• Discipline: RN
• Duration: Ongoing
• 36 hours per week
• Shift: 12 hours
• Employment Type: Staff

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This position may qualify for a sign-on bonus.  

SUMMARY:

Responsible for improving overall quality and completeness of clinical documentation. Performs concurrent record reviews on all selected admissions and documents findings. Facilitates modifications to clinical documentation to accurately reflect patient severity of illness and risk of mortality through extensive interaction with physicians, case management, nursing staff, other patient care givers and health information management coding staff.    Ensures the accuracy and completeness of clinical information used for measuring andreporting physician and hospital outcomes.    Maintains accurate record of review activities to comply with departmental and regulatory agency guidelines. Understands and complies with policies and procedures related to confidentiality of medical records. Identifies opportunities for interdepartmental and intradepartmental operational improvements. Participates in program related meetings, physician and staff education, staff development, departmental activities and in-service opportunities. Completes established competencies for the position within designated introductory period. Other related duties as assigned.
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• Communicates with the individual physician or medical staff departments to facilitate complete and accurate documentation of the inpatient record
• query process.
• Serves as a resource for physicians to help link ICD-10-CM/PCS coding guidelines and medical terminology to improve accuracy of patient severity of illness, risk of mortality, and final code assignment
• Works in collaborative fashion with the Coders and Case Managers concurrently reviewing the inpatient medical record to assure correct provisional and final DRG assignment
• Monitors and evaluates effectiveness of concurrent chart review and query outcomes at designated intervals
• Reports concurrent chart review and query outcomes to hospital departments and committees at designated intervals
• Performs monthly closed chart reviews and serves on the Chart Documentation Committee
• Identifies, assist and participates in intradepartmental and interdepartmental special projects involving accuracy of physician documentation and reporting outcomes
• Utilizes resources efficiently and effectively
• Maintains safe environment
• Participates in Performance Improvement activities

Baptist Health System - San Antonio Job ID #2503030968. Posted job title: Specialist Clinical Documentation I (CDI Specialist)

• Health Care FSA
• Dependent Care FSA
• Life insurance

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