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Registered Nurse/Clinical Documentation Improvement Specialist - AMB -FT Day

Charlotte, NC, United States
Job ID: 47692
Job Family: Nursing
Status: Full Time
Shift Details: Regular
Department Name: 21101017240504-Administration - Operations
Location: Charlotte - 2709 Water Ridge Pkwy


Job Summary

Responsible for concurrently reviewing inpatient medical records to identify vague, inconsistent or incomplete documentation within the medical record and assigns the most appropriate medical severity diagnostic related group (MS-DRG).

Essential Functions

  • Reviews selected populations of inpatient medical records to identify the principal and/or secondary diagnoses. Appropriately assigns the MS-DRG that most accurately reflects the severity of illness of the patient based upon the clinical evidence documented at the time of the record review.
  • Demonstrates knowledge and understanding of severity based DRG systems; All Patient Refined and Medicare Severity (AP-DRG) and Medical Severity Diagnostic Related Group System (MS-DRG).
  • Demonstrates the ability to utilize the licensed software tool to perform and record daily medical record reviews.
  • Interacts with the physician and/or other designated members of the healthcare team to ensure that vague or incomplete documentation is clarified within the medical record in a timely manner.
  • Works with other departments such as coding, corporate compliance, quality, and finance to support Corporate Goals.
  • Participates in the ongoing education of physicians, nurse practitioners, physician assistants and other healthcare team members in an effort to identify medical record documentation improvement opportunities employing conflict resolution skills as necessary.
  • Utilizes critical thinking skills based upon extensive knowledge of disease processes and clinical outcomes to identify the need for further clarification of physician documentation within the medical record.
  • Ensures that all written requests to physicians for additional documentation support Corporate Compliance policies.

Physical Requirements

Works in an office type setting, extensive walking throughout the facility. Prolonged periods of sitting reviewing medical records and documentation. Repetitive wrist motion and occasional lifting of 10-20 pounds. Intact sight and hearing with or without assistive devices is required.

Education, Experience and Certifications

Registered Nurse North Carolina Licensure required. Bachelor’s Degree Required. Appropriate professional certification required within 3 years of hire date per department protocol. 5 years of related nursing experience preferred. Clinical experience within the assigned population. Extensive knowledge of disease processes and clinical outcomes. Case Management experience or background helpful. Strong financial and analytical skills preferred. Word, Outlook, Excel experience preferred. Must speak English fluently and write English in understandable terms.