VCU Health System's Clinical Documentation Improvement department is seeking a full time Clin Doc Review Specialist. This position will facilitate modifications to clinical documentation through concurrent (pre-bill) interaction with providers and other members of the healthcare team. Promote capture of clinical severity (later translated into coded data) to support the level of service rendered to relevant patient populations.
Reviews inpatient medical records on a daily basis, concurrent with patient stay, to identify opportunities to clarify missing or incomplete documentation.
Collaborates with providers, case managers, coders, and other healthcare team members to facilitate comprehensive health record documentation that reflects clinical treatment, decisions, diagnoses, and interventions.
Utilizes the hospital's designated clinical documentation system to conduct reviews of the health record and identifies opportunities for clarification.
Conducts follow-up of posted queries to ensure that queries have been answered and physician responses have been appropriately documented.
Collaborates with CDI Educator to coordinate education related to compliance, coding, and clinical documentation issues within the healthcare organization, including rounding with the multidisciplinary healthcare team.
Functions as a consultant to coding professionals when additional information or documentation is needed to assign coded data.
Evaluates how the health record translates into coded data, including review of provider and other clinician documentation, lab results, diagnostic information, and treatment plans.
Bachelor's Degree in Nursing from an accredited School of Nursing
Current RN licensure in Virginia or eligible
Three (3) years of inpatient clinical nursing experience in an Integrated Health System
Experience with personal computers and e-mail applications, internet and Microsoft applications, to include Word, Excel, Access and PowerPoint
Knowledge of quality improvement theory and practice, core measures, safety, and other required reporting programs
Minimum of five (5) years as a Clinical Documentation experience in an Integrated Health System
Previous work one (1) experience with MS DRG's , APR-DRG's, Severity of Illness (SOI) and Risk of Mortality (ROM)
Previous work experience with coding and clinical documentation software
Knowledge of federal, state, and private payer regulations
Registered Health Information Technologist/Administrator (RHIT /RHIA) OR Certified Coding Specialist (CCS) with years of inpatient coding in an acute care setting OR Clinical Documentation Improvement Professional (CDIP)(AHIMA) OR Certified Clinical Documentation Specialist (CCDS) (ACDIS)