Registered Nurse - Clinical Documentation Specialist - Full Time Days

Job Description

Summary

ABOUT WILLIAMSON HEALTH | Williamson Health is a regional healthcare system based in Williamson County, Tennessee, with more than 2,300 employees across more than 30 locations and more than 860 physicians and advanced care practitioners offering exceptional healthcare across 60-plus specialties and subspecialties close to home. The flagship facility, Williamson Medical Center, which recently opened its new Boyer-Bryan West Tower, offers extensive women's services, state-of-the-art cardiology services, advanced surgical technologies, an award-winning obstetrics and NICU, leading-edge orthopaedics, outpatient imaging services, and distinct comprehensive emergency and inpatient services for both adult and pediatric patients. Other Williamson Health service providers include the Bone and Joint Institute of Tennessee, The Turner-Dugas Breast Health Center, Monroe Carell Jr. Children's Hospital Vanderbilt at Williamson Medical Center, Williamson Health physician practices that are strategically located throughout the community, countywide Emergency Medical Services that include 18 rapid response units, Williamson Health Foundation, and multiple joint venture Vanderbilt Health and Williamson Medical Center Walk-In Clinics in Williamson County. Learn more about our many specialized services at WilliamsonHealth.org.

Williamson Health is a system where your talents will be valued and your skillset expanded. We are rooted in our promise to world-class, compassionate care for the residents of Williamson County and surrounding communities, taking exceptional pride in serving our community. We're committed to empowering our employees to work in innovative ways and reserve time and space for curiosity, laughter and creativity. We value and support the diversity and cultural differences among one another and are committed to upholding an inclusive environment that appreciates the uniqueness of all individuals. Our values are at the heart of everything we do : respect for every individual, the health and total well-being of all people, human compassion and integrity. These shape who we are as an organization and are essential for delivering the highest level of culturally competent care and treatment of every patient, family member, visitor, physician and employee.

Williamson Health is pleased to offer a comprehensive benefits program, that offers you choice and flexibility, so you can take charge of your physical, financial, and emotional well-being.

o Medical, Dental, Vision

o PTO

o Retirement Matching

o Tuition reimbursement

o Discount programs

o FSA (Flexible Spending Accounts)

o Identity Theft Protection

o Legal Aid

Williamson Health is an equal-opportunity employer and a drug-free workplace.

Position Summary :

Under the oversight of the HIM Director and HIM Manager, the CDS facilitates accurate documentation for severity of illness and quality in the medical record. This involves extensive record review, interaction with physicians, health information management professionals, and nursing staff. Active participation in team meetings and education of staff in the CDMP® process is a key role.

The CDS must be able to collaborate in a positive and productive manner with the health care clinicians, health care providers, HIM team, CDI team, Revenue Cycle team, and the hospital administrative team. Adherence to TN State requirements, Joint Commission requirements, and HIPAA regulations is critical. Other duties as assigned.

Position Requirements :

Formal Education / Training :

Must be currently licensed by the State of Tennessee as a Registered Nurse.

Graduation from a program of Nursing, BSN preferred.

CDIP or CCDS Preferred

Workplace Experience :

Recent Emergency Room and or Critical Care experience preferred

Equipment and Skills Training :

• Demonstrated clinical knowledge base in critical care, emergency medical / surgical nursing.
• Demonstrated organization, problem solving and critical thinking skills.
• Able to perform independently and in team situations under the supervision of a Director.
• Efficient review and interpretation of the medical record.
• Familiar with Meditech preferred.
• Working knowledge of reimbursement issues, Medicare DRG system.
• Excellent computer and Microsoft Office skills required.
• Excellent interpersonal and teamwork skills.
• Strong analytical skills and ability to comprehend and analyze large quantities of operational data.
• Must be able to use standard office equipment and information systems.
• Exceptional organizational skills with attention to detail.
• Ability to work independently within established guidelines.
• Excellent oral and written communication skills required.
• Must be able to proactively prioritize work and have a keen ability to multi-task.
• Ability to adapt to changes in the workload and work functions.

Physical Environment :

Office and Clinical environment.

Physical Effort :

Able to use the telephone and computer for extended periods of time.

Clear understandable voice.

Key Results :

Completes assigned reviews of the medical record within 24 hours or next business day for completeness and accuracy for severity of illness (SOI) and quality using the Compliant Documentation Management Program® (CDMP®) documentation strategies. Iodine's "Best Practice" is 90% review of patients who were ever prioritized. De-prioritized patients after d / c are not marked in list.

Timely follow up and / or elevation on cases and follow up of those with clinical documentation clarifications. Follows up via approved pathway(s) and / or elevates appropriately for queries past expected due date within two business days.

Recognize opportunities for documentation improvement, as evidenced by appropriate detailed, clinically credible queries.

Works in a professional and team building manner with all other departments (Ie, Quality, HIM, Coding, physicians, providers, Admin, Case Mgt / HIM Committee, etc)

Demonstrate Critical thinking, problem solving and deductive reasoning skills, escalating cases according to process.

Displays evidence of knowledge of Pathophysiology and Disease Process, as evidenced by clinically sound queries and discussions with MD's.

Creates appropriate and effective clarification queries to providers and assists co-workers with this as needed as well.

Participates in Task Force Meetings and attends / actively participates in departmental and process improvement team meetings as needed; offers additional education to MD's where indicated.

Displays effective and positive communication with HIM staff, physicians, Quality, and coders and resolves discrepancies.

Identifies and reports any issues related to potential or actual documentation trends or issues which need further review.

Must be able to proactively prioritize work and have a keen ability to multi-task. Ability to adapt to changes in the workload and work functions.

Other duties as assigned.