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Clinical Documentation Specialist - RN (Roanoke, VA, US, 24011)

Company: Carilion Clinic
Location: Roanoke
Posted on: September 12, 2023

Job Description:

How You'll Help Transform Healthcare: You're an accomplished nurse and a talented leader. Step up and join the extraordinary nurses providing extraordinary care at Carilion Clinic, a Joint Commission-accredited network that includes seven hospitals, two of which are Magnet --designated; multi-specialty physician practices; and affiliations with prestigious academic medical institutions. Accountable for improving the overall quality and completeness of physician and NP/PA clinical documentation of diagnoses and procedures used in inpatient admissions. - -Facilitates clinical documentation improvement through extensive daily interaction with physicians, midlevel providers, healthcare team and coding staff to achieve timely, accurate, and complete documentation. Provides for a complete medical record at patient discharge which accurately captures the patient's acuity and severity levels. - -Ensures documentation that results in accurate clinical data to measure and report outcomes which support appropriate reimbursement for the level of services rendered to the patient. - -Educates all members of the patient care team on clinical documentation improvement. Concurrently reviews inpatient medical records to identify documentation opportunities: a. - -Reviews all clinical documentation to assure all pertinent conditions are documented to reflect severity of illness and acuity of care; b. - -Establishes the working DRG assignments. - -When necessary, collaborates with coding liaison to determine accurate working DRG. c. - -Identifies and queries physicians, nurse practitioners, and physicians' assistants of potential clarifications related to the principal diagnoses, comorbid conditions and complications, and/or procedures based upon industry standards, hospital policy, and clinical indicators; assures physician documents their responses within the - -record in a compliant manner; d. - -Ensures timely data entry and closure of cases in electronic database. e. - -Conducts follow-up reviews to ensure points of clarification have been recorded in the patient's medical record. Must possess a high level of clinical knowledge regarding the patient population served - -in order to - -participate collaboratively with all members of the care team. - -Must demonstrate knowledge of the principles of disease definitions and the principles of growth and development over the lifespan of the patient (neonate to geriatrics). - -Must possess the ability to assess data reflective of the patient's clinical status, interpret the appropriate -information needed to identify each patient's acuity and severity of - -illness. Works with minimal supervision. What We Require: Education: Bachelor's degree or equivalent 8 years of experience required. Experience: 5 years of recent experience in a clinical hospital healthcare setting - Licensure, certification, and/or registration: Current licensure in Virginia as a Registered Nurse - Other Minimum Qualifications: Must demonstrate knowledge and competency in the following areas: satisfactory completion of orientation; positive interpersonal and communication skills; critical analysis skills; ability to resolve complaints/problems; customer-focused philosophy of service delivery; ability and willingness to work as an integral member of a multi-disciplinary team; demonstrate ability to use technology and appropriate software to support daily activities. About Carilion Below are our core values that we strive to embody and expect of all our team members: Collaboration: Working together with purpose to achieve shared goals. Commitment: - -Unwavering in our quest for exceptional quality and service. Compassion: - -Putting heart into everything we do. Courage: - -Doing what's right for our patients without question. Curiosity: - -Fostering creativity and innovation in our pursuit of excellence. Requisition Number: 141158 - Employment Status: Full time - Location: CASB - Carilion Administrative Services Building - Shift: Day/Evening - Shift Details: Prim. Monday - Friday, Flexible hours Recruiter: DANA E JOHNSON - Recruiter Phone: 540-400-4631 - Recruiter Email: dejohnson@carilionclinic.org For more information, contact the HR Service Center at 1-800-599-2537. Equal Opportunity Employer Minorities/Females/Protected Veterans/Individuals with Disabilities/Sexual Orientation/Gender Identity Carilion Clinic is a drug-free workplace.

Keywords: Carilion Clinic, Roanoke , Clinical Documentation Specialist - RN (Roanoke, VA, US, 24011), Healthcare , Roanoke, Virginia

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