Job Description

Overview

Clinical Documentation Specialist - RN, Remote

40 hours per week

Facilitates improvement in the overall quality, completeness and accuracy of medical record documentation. Educates members of the patient care team on documentation guidelines.

*CDI specific experience preferred

These are just a few highlights of being a nurse at Dartmouth Hitchcock Medical Center and Clinics:

• We have loan repayment up to $20,000.
• We offer generous tuition reimbursement.
• We have a very popular "earned time" plan.
• We have extensive CEU/Training programs.
• Our nurses serve as central figures in the success of our system through our shared governance nursing model.
• We offer a rigorous, research-focused environment.
• Dartmouth Hitchcock's Nursing Continuing Education Council is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center.

Why are we so unique? We are a nationally recognized Academic Medical Center set right in the middle of the White Mountains of New Hampshire.

Read more about Dartmouth Health and why YOU should work here.

The Dartmouth Health system stretches over New Hampshire and Vermont and offers the quintessential New England experience. With no income or sales tax, this beautiful area combines history, industry, and business and has been ranked consistently as one of the best places in the US to live and work. Anchored by the academic Dartmouth Hitchcock Medical Center in Lebanon, NH, the system includes the NCI-designated Dartmouth Cancer Center, Dartmouth Health Children’s; member hospitals, and 30 Dartmouth Hitchcock ambulatory clinics across the region.

Applicants are encouraged to visit our nursing career site to learn more and apply:

Please visit: https://dhnursing.org/nursing-careers/

Dartmouth Health is an equal opportunity employer, and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability status, veteran status, gender identity or expression, or any other characteristic protected by law.

Responsibilities

Performs ongoing medical record reviews using documentation improvement guidelines. Evaluates overall quality and completeness of clinical documentation. Conducts follow-up reviews of clinical documentation.

Initiates and maintains interactions with physicians and mid-level providers on a concurrent basis to address the need for more detailed information in the medical record.

Ensure the severity of illness and level of services provided are accurately reflected in the medical record.

Reviews clinical picture of the patient and assigns a working DRG. Ensures the working DRG is entered in the appropriate database/IDX system and trends completion of DRG worksheets.

Establishes and maintains a system to track and analyze outcomes of documentation improvement program. Prepares regular outcomes progress reports and presents.

Facilitates and participates in regular team meetings with the Coding staff.

Works with inpatient coders to ensure appropriate DRG assignment and that reimbursement reflects the level of services rendered.

Uses performance improvement methodologies and education strategies to develop formal training and improvement programs for the staff concerning clinical documentation opportunities, coding and reimbursement issues. Provides ongoing updates as regulations change.

Educates Coding team members on clinical (diagnostic and therapeutic) updates on an ongoing basis.

Utilizes nursing and clinical knowledge to respond to payors concerning clinical denials, as assigned

Provides clinical documentation expertise to assist in resolving outpatient issues involving physician documentation.

Performs other duties as required or assigned.

Qualifications

• Must have the ability to create and maintain strong relationships and confidently discuss clinical diagnoses.
• Excellent verbal and written communication abilities required.
• Demonstrated interpersonal skills, including negotiation, conflict resolution, follow-through and follow-up.
• Must have good organizational skill including project management, with attention to detail and accuracy.
• Must possess the ability to develop and deliver clinical education programs on clinical documentation improvement for the Medical Staff and Hospital Staff.
• Must have the following computer competencies: data entry and analysis, word processing, and presentations.
• Knowledge of DRG prospective payment systems, documentation & coding guidelines and compliance requirements preferred.
• Current knowledge of DRGs and payment regulations preferred.
• Up-to-date clinical knowledge, understand clinical picture of the patient condition and identify opportunities for improved documentation.
• 3 years of applicable experience.

Required Licensure/Certifications

• Licensed Registered Nurse with NH eligibility