Cook Children's Healthcare Clinical Documentation Spec in Fort Worth, Texas

Clinical Documentation Spec

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1st Shift



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SUMMARY: Utilizes clinical expertise to analyze, evaluate and promote complete, accurate and meaningful patient record documentation that clearly describes a patient's condition, severity of illness, complexity, acuity and resources used in a patient's care. Ensures patient health care record documentation is clear and complete, reflects clinical decision making, and captures the appropriate clinical severity of illness and services rendered to the patient. Utilizes experience, knowledge and confidence to facilitate modifications to clinical documentation through concurrent collaborative interaction with providers and other members of the healthcare team to assure documentation of clinical severity that supports the level of services rendered to patients, quality initiatives, coding, billed charges, revenue, research, accurate reporting of public data and other health care functions. Demonstrates knowledge and understanding of complications, comorbid conditions, severity of illness, risk of mortality, case mix Index, and impact on coding, billing and revenue, as well as the ability to impart this knowledge in a professional and collegial manner to physicians, other members of the healthcare team and Cook Children's leadership. Works independently in patient care areas collaborating extensively with physicians, nursing staff, and other providers to improve the accuracy, quality and completeness of documentation. Collaborates with coding team to assure accurate coding, DRG assignment and regulatory compliance. Provides education of CDI process to all providers, coders and other individuals and groups. Utilizes CDI computer database to track and trend documentation improvement and compliance to sustain positive outcomes for both internal and external public reporting. Maintains current and thorough knowledge and understanding of clinical care, treatment, documentation requirements, Meditech, Athena, coding schemes, DRG groupers, policies, procedures, regulatory requirements and guidelines and standards. QUALIFICATIONS: ASN, current Registered Nurse with at least five (5) recent year's clinical experience required. BSN preferred. Pediatric Experience strongly preferred At least 3 years job related experience in quality management/improvement, case management and/or discharge planning experience required. Hospital inpatient coding and DRG analysis/management and documentation improvement experience in an acute care setting (prefer Pediatric) with knowledge and understanding of Joint Commission accreditation, CMS regulations, Texas Department of Health and other regulatory requirements highly desired; Must have sharp analytical and critical thinking skills, must be highly detail oriented, computer literate; have strong organizational, interpersonal and written/oral communication skills with ability to adapt to changing health care environment; ability to maintain confidentiality; have appropriate professional interpersonal style to establish effective relationships with customers and internal partners in a way that promotes openness and trust to achieve positive outcomes; energetic, goal and team oriented. Maintain effectiveness when experiencing major changes in work responsibilities or environment; adjust effectively to work within new work structures, processes, requirements or cultures. Current Registered Nurse Licensure in the State of Texas; Certified Clinical Documentation Specialist (CCDS) obtained within 2 years of hire date. *LI-MK

EOE/AA, M/F/Disability/Vet