WellSpan Health Clinical Documentation Nurse (RN) - Good Samaritan Hospital - Part time in Lebanon, Pennsylvania
Clinical Documentation Nurse (RN) - Good Samaritan Hospital - Part time
General Summary:Under general supervision of the Manager-Clinical Documentation Improvement, reviews medical record documentation to facilitate the accurate representation of the severity of illness, patient acuity and risk of mortality for a specified patient population. Obtains appropriate clinical documentation through extensive interaction with physicians, healthcare providers and Health Information Management (HIM) professionals. Actively participate in meetings and education of staff related to the Clinical Documentation Management Program (CDMP).
Duties and Responsibilities:The following are essential job accountabilities: 1 Facilitates modifications to clinical documentation to ensure that appropriate reimbursement is received for the level of service rendered to all patients by completing accurate and timely record reviews. 2 Demonstrates knowledge of Diagnosis Related Group (DRG) payer issues, documentation opportunities, and clinical documentation requirements. 3 Knowledge of Medicare, general understanding of hospital based quality initiatives, and regulatory environment. 4 Improves the overall quality and completeness of clinical documentation by performing admission and continued stay reviews. 5 Completes timely follow up on all cases, especially those with clinical documentation clarifications and ensures points of clarification have been recorded in the patients medical record. 6 Formulates ethical and clinically credible documentation clarifications. 7 Effectively and appropriately communicates with physicians and healthcare providers. 8 Ensures the accuracy and completeness of clinical information used for measuring and reporting physician and hospital outcomes. 9 Processes discharges by updating the DRG Worksheet to reflect any changes in status, procedures and treatments, and confers with physician to finalize diagnoses. 10 Educates all internal customers on compliant documentation opportunities, coding and reimbursement issues, as well as performance improvement methodologies. 11 Prepares educational materials for presentation at meetings, physician grand rounds, interdisciplinary rounds, physician staff meetings, and participates in new provider orientations. 12 Reviews clinical issues with coding staff to assign a working DRG and reconcile final DRG. 13 Serves as a member of the Clinical Documentation Improvement Task Force. 14 Accurate input of data into the CDMP Guide software.
WellSpan Health is an integrated health system that serves the communities of central Pennsylvania and northern Maryland. The organization is comprised of a multi-specialty medical group of more than 850 physicians and advanced practice clinicians, a home care organization, six respected hospitals, more than 15,000 employees, and 160 patient care locations. The region's only accredited Level 1 Trauma Center and Primary Stroke Center with an endovascular neurosurgery program. WellSpan is consistently recognized by IMS Health as one of the Top 100 Integrated Health Networks in the United States and has been recognized by Health Imaging and IT as one of the nation's "Top 25 Connected Healthcare Facilities." IMS Health is the leading provider of information services and technology for the healthcare industry.
WellSpan Health facilities are located in multiple counties across south central Pennsylvania and northern Maryland, all offering an ideal living environment to match the quality of work-life balance you’re seeking. The area offers abundant outdoor and cultural activities, including restaurants, theatre, golf courses, hiking trails, water sports and historic tours. Additionally, our communities are a short drive from several, large metropolitan areas including the Baltimore/DC metro area and Philadelphia.
If you value a strong sense of community, the more palatable pace of rural living, and the convenience of a workplace close to home, you’ll realize the advantages of considering WellSpan Health as part of your future.
5 years recent hospital experience with ICU experience
Case management preferred
Clinical Nurse II for internal applicants
Registration and current Registered Nurse license in PA
Lebanon, Pennsylvania, United States
Additional Scheduling Info
40 hours biweekly, day shift