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Clinical Documentation Registered Nurse II, Clinical Documentation Integrity - Full Time
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Full-time
- The clinical documentation RN will provide support and expertise through comprehensive assessment and review of inpatient medical records.
- The clinical documentation RN will facilitate accurate DRG assignment and obtain appropriate documentation through extensive interaction with physicians, patient caregivers and health information management coding staff to ensure that reimbursement is received for the level of services rendered to the patients.
- Analyzes clinical status of patient, current treatment plan and past medical history and identifies potential gaps in physician documentation
- Maintains an electronic DRG worksheet to assist coders on identifying all documented diagnosis and procedures
- Updates DRG worksheet to reflect any changes inpatient status/procedure/treatment and confers with the physician to finalize diagnosis
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