Harborview Medical Center
Healthcare
RegisteredNurse,CDI(ClinicalDocumentation)
“Registered Nurse, CDI (Clinical Documentation) at Harborview Medical Center. Skills: Clinical documentation improvement, Registered Nurse, Medical and surgical care of patients. Improving the overall quality and completeness of clinical documentation. Facilitating modifications to clinical documentation through extensive interaction with physicians, nursing staff, other patient caregivers, and medical records coding staff”
What You'll Achieve.
Improving the overall quality and completeness of clinical documentation; Ensuring that appropriate reimbursement is received for the level of service rendered to all patients with a MS-DRG or AP-DRG based payer; Ensuring the accuracy and completeness of clinical information used for measuring and reporting physician and medical center outcomes; Adding to the accuracy and specificity of the medical record
Industry & Context.
Problem solving
Fully remote position
What They're Looking For.
Must Have
Current license to practice as a Registered Nurse in the State of Washington (or current multistate RN license), Minimum of 2 years in a clinical documentation improvement position, Minimum of 6 years of recent acute inpatient hospital nursing experience with in-depth knowledge of medical and surgical care of patients
Nice to Have
BSN premium, nursing certification premium
What You'll Do.
Improving the overall quality and completeness of clinical documentation
Facilitating modifications to clinical documentation through extensive interaction with physicians
other patient caregivers
and medical records coding staff
Ensuring that appropriate reimbursement is received for the level of service rendered to all patients with a MS-DRG or AP-DRG based payer
Ensuring the accuracy and completeness of clinical information used for measuring and reporting physician and medical center outcomes
Educating all members of the patient care team on an ongoing basis
Facilitating modifications to clinical documentation to ensure that appropriate reimbursement is received for the level of service rendered to all patients with a DRG or APDRG based payer
Educating internal customers (physicians
etc.) on compliant documentation opportunities
adding to the accuracy and specificity of the medical record
Conducting follow-up reviews of clinical documentation to ensure points of clarification have been recorded in the patient’s chart
Participating in QA studies as assigned for Quality Core Measures
Patient Safety and Hospital Acquired Conditions
referring quality issues to appropriate resources
How You'll Work.
Team & Collaboration
Extensive interaction with physicians, nursing staff, other patient caregivers, and medical records coding staff; Educating all members of the patient care team on an ongoing basis; Educating internal customers (physicians, nurses, etc.) on compliant documentation opportunities
Communication Scope
Written communication skills; Verbal communication skills
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