St. Dominic Hospital

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RN Documentation Specialist

at St. Dominic Hospital

Posted: 8/27/2020
Job Reference #: 11080

Job Description

Employment Type:
Full Time
Other Shift Details:
Job Code:



Job Summary
Responsible for conducting concurrent review of designated medical records to improve and ensure the quality and completeness of clinical documentation. Initiates queries in cases when information is incomplete, contacts physicians as appropriate or routes incomplete query forms to HIM personnel. Ensures the accuracy and completeness of clinical information used for review of physician profiles. Educates physicians on an ongoing basis. Assists with training of new documentation specialists.
Job Requirements
Minimum Education
Graduate of an accredited school of nursing.
Required Licenses[Mississippi, United States] Registered Nurses
Current licensure in good standing in the state of Mississippi.
Required Skills
Case management of utilization management experience preferred. Requires oral and written communication skills;professional conduct and appearance.
Essential Functions
Maintains established departmental policies and procedures, objectives, quality assurance program, safety, environmental and infection control standards.Facilitates documentation and clarification of clinical information to ensure complete and compliant medical records that accurately reflect the level of service rendered.Performs admission and continued stay reviews using appropriate documentation guidelines.Maintains and completes the DRG Clinical Worksheet on assigned patients; enters information in tracking database after final DRG assignment.Educates physicians regarding documentation requirements and coding guidelines.Maintains daily productivity records and submits to Director of HIM as scheduled.Participates in meetings with coding personnel on a weekly basis.Attends Medical Staff division meetings as assigned by the Director of HIM.Trains new documentation specialists as necessary.Keeps abreast of current trends in areas of documentation and coding.Additional Responsibilities: Supports the hospital's Christian mission, philosophy, values and goals.Participates in and supports established Performance Improvement Programs.Attends JCAHO and mandatory inservice programs, completes fraud and abuse educational program on an annual basis.Observes hospital dress code and maintains appropriate conduct and appearance.Maintains confidentiality of all information regarding patients, families, physicians and hospital personnel.

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