Clinical Documentation Registered Nurse - Clinical Documentation Integrity
Company: CHRISTUS Health
Location: Alexandria
Posted on: March 28, 2026
|
|
|
Job Description:
Description Summary: The Clinical Documentation Registered Nurse
collaborates extensively with physicians, nursing staff, other
patient caregivers and coding staff to improve the quality and
completeness of documentation of care provided and coded for
coordination, abstraction and submission of accurate data required
by CMS. Facilitates concurrent modifications to clinical
documentation to insure commensurate reimbursement of clinical
severity and services rendered to patients with a DRG based payer
(Medicare, Medicaid). Supports timely, accurate and complete
documentation of clinical information used for measuring and
reporting physician and facility outcomes. Communicates with and
educates all clinical staff concerning accurate and effective
clinical documentation. Responsibilities: Reviews inpatient medical
records for identified payer populations as within one business day
of admission and throughout hospitalization to identify
opportunities for physician documentation. Analyzes clinical status
of patient, current treatment plan, and past medical history and
identifies potential gaps in MD documentation and leaves physician
query to obtain complete, accurate clinical documentation. Works
closely with HIM coding staff to assure documentation of discharge
diagnosis and any co-existing co-morbidities is a complete
reflection of the patient’s clinical status and care Maintain a DRG
worksheet to assist coders on identifying all documented POA/HAC,
diagnosis and procedures Updates DRG worksheet to reflect any
changes to inpatient status/procedure/treatment and confers with
the physician to finalize diagnosis. Demonstrates basic knowledge
about HIM coding standards and applies to ongoing evaluation of
medical record documentation for accuracy of physician
documentation to support the acuity of illness. Performs chart
review on expired patients to identify severity of illness and risk
of mortality for performance improvement activities. Develops and
implements plans for both formal and informal education of
physician, nursing, and other clinical staff on clinical
documentation opportunities, coding and reimbursement as well as
performance improvement methodologies. Collaborate with case
manager regarding cases with length of stay outside of the expected
GMLOS, to ensure documentation identifies severity of illness and
maximizes reimbursement potential. Coordinates and assures complete
and accurate data collection and validation for public reporting
data initiatives for Premier, CMS and JCAHO. Maintains good rapport
and cooperative relationships. Approaches conflict in a
constructive manner. Helps identify problems, offers solutions, and
participates in their resolution. Coordinates with quality
department by: providing concurrent review for core measures
documentation, providing retrospective chart audits as needed, and
educating nursing and medical staff of improvement and current
status of quality initiates. Performs follow-up to document
physician response to queries. Tracks and trends patterns of
physician responses and reports monthly to director. Designs and
implements collaboration with physician leadership specific tools
to support medical record physician documentation. Review clinical
issues with coding staff to assign working DRG’s. Work
collaboratively with the coding staff to ensure that documentation
of discharge diagnoses and co-morbidities are a complete reflection
of the patient’s clinical status and care. Review final DRG and
compare with clinical data gathered to ensure the DRG assigned is
appropriated and that all co-morbidities are captured. Communicates
with Case Management Director and/or Vice President of Medical
Affairs regarding program barriers/success/outcomes of CDI program.
Assists in collection and organization of data for analysis by
appropriate medical and hospital committees. Consistently meets
established productivity targets for record review. Maintain strict
confidentiality at all time. Performs other duties as assigned.
Requirements: Associate's Degree in Nursing RN License in state of
employment or compact Work Schedule: PRN Work Type: Per Diem As
Needed
Keywords: CHRISTUS Health, Alexandria , Clinical Documentation Registered Nurse - Clinical Documentation Integrity, Healthcare , Alexandria, Virginia
