Major Responsibilities:
- Improves the overall quality and completeness of clinical documentation by performing chart reviews using clinical documentation guidelines based on accepted standards, evidenced based practice, and current regulatory requirements.
- Educates all internal customers on clinical documentation opportunities, coding and reimbursement issues, as well as performance improvement strategies.
- Maintains the integrity of databases, tracks and trends response to clinical documentation and measures for performance improvement.
- Demonstrates positive and effective interpersonal relations dealing with all members of the team (i.e., co-workers, physicians, leadership, etc.).
Licensure:
Education/Experience Required:
- Graduate from an accredited school of nursing (BSN) with 5 years of relevant clinical experience; clinical documentation improvement experience preferred.
Knowledge, Skills & Abilities Required:
- Ability to prioritize work.
- Excellent communication skills.
- Good problem-solving skills.
- Critical thinking skills.
- Basic computer skills.
- Effective problem-solver with good interpersonal communication skills, both verbal and written.
- Effective observation, analytical, and critical thinking skills.
- Current nursing license in the State of Illinois; certification in clinical documentation improvement preferred.
Physical Requirements and Working Conditions:
- Ability to work in a changing environment.
- Ability to prioritize independently and respond to multiple simultaneous requests.
- Ability to work under stressful conditions and in difficult situations.
- May be exposed to hazardous materials and life-threatening diseases.
- This position needs to recognize needs and behaviors of specific age groups of patients treated.
- Extensive knowledge and experience of ICD-10 coding classification system and DRGs.
This job description indicates the general nature and level of work expected of the incumbent. It is not designed to cover or contain a comprehensive listing of activities, duties, or responsibilities required of the incumbent. The incumbent may be required to perform other related duties.
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