PRIMARY FUNCTION:

Responsible to ensure that health care services are administered with quality, cost efficiency, and within compliance, along with improving and ensuring the overall quality, cost efficiency and completeness of documentation within the inpatient medical record. Continuously reviewing and auditing patient medical records (observation and inpatients), screening for unnecessary procedures, ineffective treatments, and unnecessarily extensive hospital stays. Educates members of the patient care team on documentation guidelines on an ongoing basis. Facilitates modifications to clinical documentation through extensive concurrent interaction with physicians, coding staff and other members of the healthcare team to support the appropriate reimbursement and clinical severity are captured compliantly for the level of service rendered to all patients.

PRINCIPAL DUTIES AND RESPONSIBILITIES:

• Concurrent review of observation and inpatient medical records throughout the patient's hospitalization.
• Analyzes clinical status of patient (Observation v. Inpatient), current treatment, past medical history and identifies potential gaps in physician documentation.
• Communicates with physicians or other providers to validate admission status and appropriately prompts for documentation if necessary, either verbally or written; educates these same individuals to improve documentation.
• Ensures Medicare compliance via utilization management
• Demonstrates proficient knowledge of HIMS standards of coding and applies to ongoing evaluation of the medical record documentation.
• Reviews and clarifies clinical issues in the health record with the coding professionals that would support an accurate DRG assignment, severity of illness, and/or risk of mortality.
• Monitors patients progress; consults with primary physician or designee and other members of the care delivery team at agreed-upon intervals, or more frequently, as needed.
• Attends coding/financial/utilization management educational programs and regulatory educational programs and updates as necessary to maintain proficient knowledge base.

EDUCATION AND EXPERIENCE REQUIREMENTS:

• Bachelor's Degree in Nursing
• Registered RN licensed to practice in the State of DE required
• Minimum of 3 years recent experience as a Registered Nurse in acute care, adult care setting,
• Clinical Documentation, Performance Improvement, Case Management or Utilization Management experience desirable.
• Clinical Documentation Certification (CCDS) required within 1 year of eligibility