Job Description

Job Description

Certification Details

• BLS
• Wisconsin Registered Nurse License or Multi-state Nursing License (Nurse Licensure Compact)
• CDI advanced certification (CCDS or CDIP) required within 6 months

Job Details

• Responsible for improving the overall quality and completeness of clinical documentation.
• Facilitates modifications to clinical documentation through extensive interaction with physicians, nursing staff, other patient caregivers, and medical records coding staff to ensure compliant documentation and appropriate reimbursement.
• Ensures accuracy and completeness of clinical information for measuring and reporting physician and hospital outcomes.
• Assists Case Management Manager in overseeing Documentation Specialists including performance appraisals, workload assignments, and practice supervision.
• Plans and implements compliant documentation goals and objectives across the Community Hospital Division.
• Assists in development of agendas and materials for hospital improvement initiatives.
• Coordinates and manages program reporting and outcome measurements.
• Assists in development and updating of policies, procedures, and workflow.
• Performs initial reviews, continued stay reviews, and reconciliation process using the 3M 360 Program to improve documentation quality.
• Coordinates professional growth and staff development activities related to education, quality assurance, and outcome measurements.
• Facilitates communication with providers to clarify diagnoses, obtain needed documentation, and educate on appropriate DRG based on severity of illness and risk of mortality.
• Reviews patient records to ensure documentation clarifications are recorded.
• Educates internal customers on compliant documentation, coding, reimbursement, and performance improvement.
• Assists with recruitment and interviewing of RN Clinical Documentation Specialists.
• Serves as primary lead for orientation and training of new RN CDS.
• Assists with management of 3M 360 program and serves as subject matter expert with IT.
• Other duties as assigned.

Job Requirements

• Minimum of five (5) years in an acute care setting as an RN.
• Working knowledge of computers.
• Associate degree in Nursing required.
• Bachelor's degree in Nursing preferred.
• Current state of Wisconsin Registered Nurse License or Multi-state Nursing License from a participating state in the Nurse Licensure Compact required.
• Advanced certification related to Clinical Documentation Improvement (CDI) such as CCDS or CDIP required within 6 months of hire.

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