RN- Clinical Reviewer/Documentation Specialist

Job Description

RN- Clinical Reviewer/Documentation Specialist - Full Time

Northwest Texas Healthcare System is excited to launch a new position to continue our efforts to deliver the highest level of patient care. The Clinical Reviewer/Documentation Specialist  will provide clinically based concurrent and retrospective review of inpatient medical records to evaluate the utilization and documentation of acute care services. The goal of concurrent review includes facilitation of appropriate physician documentation of care deliver to accurately reflect patient severity of illness and risk of morality. Specific reviews are both determined internally and by requirements/requests of external payers or regulatory agencies and play a significant role in reporting quality of care outcomes and in obtaining accurate and compliant reimbursement for acute care services.

 

Duties include:

·        Provides concurrent review of the clinical documentation in the medical record.

·        Queries the medical staff and other caregivers as necessary via written/verbal communication to obtain accurate and complete physician documentation that supports the severity of patient illness and risk of mortality.

·        Performs a thorough chart review to identify that co-morbidities/complications are documented appropriately.

·        Completes the DRG worksheet and reviews documentation of the medical record every 2-3 days. 

·        Demonstrates an understanding of the importance of and makes an effort to capture all potential secondary diagnoses for profiling purposes.

·        Demonstrates creativity and enthusiasm while pursuing the goals of the department and the organization.

·        Maintains the ability to be flexible, and prioritizes daily responsibilities.

Northwest Texas Healthcare System is a 404-bed acute care and 85 bed behavioral health medical center serving the city of Amarillo and the surrounding region. We offer the ideal combination of traditional values and the most advanced technologies in healthcare, plus the conveniences of big city living in a friendly, smaller-town atmosphere. From the beauty of Palo Duro Canyon and great recreational facilities, to our quality educational system, Amarillo is a great place to live and work.

 

 

We require:

·        Knowledge of care delivery documentation systems and related medical record documents.

·        Knowledge of age-specific needs and the elements of disease processes and related procedures.

·        Strong broad-based clinical knowledge and understanding of pathology/physiology of disease processes.

·        Excellent written and verbal communication skills.

·        Excellent critical thinking skills.

·        Demonstrated good nurse-physician relationships in the past and has the ability to maintain those going forward.

·        Working knowledge of inpatient admission criteria.

·        Ability to work independently in a time-oriented environment.

·        Computer literacy and familiarity with the operation of basic office equipment.

·        Assertive personality traits to facilitate ongoing physician communication.

·        Ability to stand and walk for periods of time is required in the performance of job responsibilities.

·        Working knowledge of Medicare reimbursement system and coding structures preferred, but not required.

·        Current RN license

·        Minimum of 5 years of clinical experience in an acute care setting, (Critical Care, Medical/Surgical or  Emergency department nursing preferred; unless being assigned to a specialty service line, then minimum of 3 years experience in that service line acceptable)

 

 

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