Join our Talent Network
Skip to main content

RN Clinical Documentation Specialist

2131 South 17Th Street
Wilmington, NC
Job ID: 12830
Date Posted: Feb 3, 2023

Returning Applicant >

Job Description

Description

About NHRMC

NHRMC, established in 1967 in Wilmington, NC, is recognized as a preeminent healthcare organization focused on leading our community to outstanding health. We have an 855 bed network of hospitals and multi-specialty physician group practices with more than 200 physicians. With a network of primary, specialty, neighborhood clinics and regional medical centers; you will find our culture is the very definition of best in practice. Join us and find out how many ways NHRMC offers you the chance to focus on what really matters - our patients and community.

About the Job

Location: New Hanover Regional Medical Center (Hybrid/Remote Position)

Department: Population Health

Full Time Equivalent: FTE: 1.000000

Work Type: 64 to 80 Hours Pay Period

Work Schedule: 8HR DAY

Exempt from Overtime: Exempt: Yes

What You'll Do

Summary:
The Documentation Specialist is a Professional Registered Nurse with a broad clinical knowledge base and understanding of DRG documentation requirements who works under the supervision of the Manager of PQP Operations and Director of Clinical Quality. This clinical position uses clinical/nursing knowledge with an understanding of national coding guidelines and standards of compliance to improve overall quality and completeness of clinical documentation to coding ensure accuracy and appropriateness within the patient electronic medical record, using a multidisciplinary team process. Works collaboratively with ambulatory providers to ensure that the clinical information within the medical record is accurate, complete, and compliant. This includes accurate documentation to support the capture or Hierarchical Condition Categories (HCC), ICD-10-CM specificity and medical necessity of ambulatory visits. Educates members of the patient care team both formally and informally regarding documentation guidelines, coding requirements and service specific requirements.


Responsibilities:
1. Medical Record Review: Facilitates appropriate clinical documentation to support Hierarchical Condition Categories, ICD-10-CM specificity and medical necessity of ambulatory visits. Follows outpatient CDE processes for performing medical record reviews, identifying opportunities to improve provider documentation and querying physicians as needed to ensure that appropriate documentation appears in the medical record. Consistently meets established productivity targets for record review. Assisting with auditing data for HCC reporting from various sources.
2. Competency: Demonstrates knowledge of documentation requirements and coding guidelines that pertain to outpatient diagnosis coding to accurately reflect the complexity and medical necessity of the visit. Improves the overall quality and completeness of clinical documentation by performing systematic chart reviews on a daily basis. Analyzes clinical status of patients, current treatment plan and past medical history and identifies potential gaps in physician documentation.
3. Education: Routinely Provides one-on-one and/or group education to physicians, advanced practice providers and other key healthcare providers regarding the need for accurate, specific, and complete clinical documentation in the patient’s medical record. Interacts regularly with physicians, in the outpatient setting, providing ongoing education regarding compliant documentation. Assists with analysis, trending, and presentation of audit/review findings, potential issues, and their root cause.
4. Communication: Proactively solicits clarification from physicians to ensure key aspects of care have been appropriately recorded in the patient’s medical record. Collaborates with clinic and coding staff as needed regarding interactions with providers related to documentation in order to resolve physician queries. Communicates information effectively by responding to questions, concerns and requests promptly. Encourages communication by promoting open dialogue. Maintains good rapport and cooperative relationships. Approaches conflict in a constructive manner. Helps identify problems, offer solutions, and participates in their resolution.
5. Collaborates with other clinical disciplines and coding to ensure high quality clinical documentation and efficient, timely coding of the medical record.
6. Collaborates with Coding Department when discrepancy in medical record is identified and reviews medical record to provide clinical feedback for accurate coding of procedural codes, ICD-CM diagnosis or DRG.
7. Participates in performance improvement activities related to the operational processes for the Documentation Integrity Program as well as related organizational/departmental goals.
8. Develops collaborative relationships and promotes teamwork with coworkers and other departments.
9. Organizes and performs work responsibilities effectively and efficiently.
10. Maintains strict patient confidentiality.

Position Requirements

Credentials:
Essential:
* Registered Nurse
Nonessential:
* Cert Clin Doc Specialist
* Cert Coding Specialist
* Reg Records Administrator
* Reg Health Info Technologist

Education:
Essential:
* Associate Degree Nursing
Nonessential:
* Bachelor of Nursing

Other information:
Experience: Minimum of Five years of nursing experience; one year of experience in care of targeted patient population; experience in a broad range of clinical situations/settings. Prior health plan experience strongly considered. Demonstrates standards of performance (ownership, teamwork, communication, compassion) that support patient satisfaction and principles of service excellence.
Performs other duties as assigned.
Individual will possess commensurate combination of education, experience and qualifications.

Other Information

This position description has been designed to indicate the general nature and level of work performed by employees within this classification. It is not designed to contain or be interpreted as a comprehensive inventory of all duties, responsibilities and qualifications which may be required of the employee assigned to the position. Depending on the location of the job, duties may vary. Receipt of the job description does not imply nor create a promise of employment, nor an employment contract of any kind; my employment with the Company is at will.

  • Member Top 100 Hospitals – In 2016 NHRMC was recognized as a Top 100 Hospital demonstrating significant investment and financial sustainability for the communities we serve.
  • Newsweek's 2020 list of Best Maternity Care Hospitals - NHRMC Betty H. Cameron Women's & Children's Hospital was named as a Best Maternity Care Hospital by Newsweek.
  • Forbes America’s Best Large Employers 2018 and 2019- Link
  • Becker’s 150 Top Places to Work in Healthcare- Link
  • Healthgrades Outstanding Patient Experience

Consider a career at NHRMC and become part of this award winning team!

Share: mail

Similar Jobs

Financial Counselor

Wilmington, NC
8HR DAY

Environmental Svc Asst

Wilmington, NC
8HR DAY

Patient Access Technician

Wilmington, NC
8HR DAY

Materials Management Associate

Wilmington, NC
8HR DAY

Staff Nurse Radiology

Wilmington, NC
8HR DAY

RN Clinical Manager Glen Meade

Wilmington, NC
8HR DAY

Resource Tech - Lab - Core Lab

Wilmington, NC
8HR DAY

Patient Experience Rep - NHMG-Ogden

Wilmington, NC
8HR DAY

RN Clinical Documentation Specialist

Wilmington, NC
8HR DAY

Transporter

Wilmington, NC
8HR DAY

Phlebotomy Tech II - NHMG-16th St Lab

Wilmington, NC
8HR DAY

RN Outpatient Wound Clinic

Wilmington, NC
8HR DAY

OR Assistant I - CF - Surgery/OR

Wilmington, NC
8HR DAY

Central Sterile Tech

Wilmington, NC
8HR DAY

Financial Counselor

Wilmington, NC
8HR DAY

Data Integrity Specialist

Wilmington, NC
8HR DAY