Full Job Description
What You Will Do:
University of Maryland Capitol Region Health is an integrated not-for-profit, community-owned organization comprised of two hospitals and several other healthcare facilities providing comprehensive, quality healthcare services to the residents of Prince George's County, Maryland and surrounding areas. Both hospitals within University of Maryland Capitol Region Health have been recognized by U.S. News & World Report. University of Maryland Capitol Region Health is the largest healthcare system headquartered in Prince George's County. Facilities: Bowie Health Campus, Family Health and Wellness Center, Glenridge Medical Center, Laurel Regional Hospital and Prince George's Hospital Center. Mission: To provide comprehensive health care of the highest quality to residents and others who use our services while strengthening our relationship with universities, research and healthcare organizations to ensure best-in-class patient care.
Collaborates extensively with physicians, nursing staff, other patient care givers, and medical records coding staff to improve the quality and completeness of documentation recorded or charted by care givers. Facilitates concurrent modifications to clinical documentation to ensure commensurate reimbursement of the clinical severity and services provided to patients. Supports timely, accurate and complete documentation of clinical information used for measuring and reporting physician and facility outcomes. Educates all members of the patient care team on an ongoing basis with respect to highest quality and completeness of clinical documentation.
Facilitates modifications to clinical documentation to support appropriate reimbursement for the level of services to all patients with an APR DRG based payer.
Demonstrates knowledge of APR DRG payer issues, documentation opportunities, clinical documentation requirements, and referral policies and procedures.
Ensures the accuracy and completeness of clinical information used for measuring and reporting physician and hospital outcomes.
Assists in the screening process, makes referrals; collaborates with case managers and clinical nurse specialists to ensure continuity of patient care. Validates clinical documentation with plan of care.
Updates their findings in 3M360 for all discharges to reflect any changes in status, procedures/treatments, and confers with physician to finalize diagnoses.
Educates all internal customers on clinical documentation opportunities, coding and reimbursement issues, as well as performance improvement methodologies.
Conducts follow-up reviews of clinical documentation to ensure points of clarification have been recorded in the patient’s chart.
Reviews clinical issues with coding staff to assign a working APR DRG.
Maintains current and thorough knowledge of clinical care and treatment of assigned patient populations to critically and competently assess appropriateness of documentation.
Services as a member of the CDI work group.
Assists with special projects as needed; performs other duties as assigned.
What You Need to Be Successful:
Associates degree (2 years college) with a minimum of five (5) years medical-surgical/critical care RN experience in an acute care environment (Clinical documentation, coding management experience can be used in lieu of RN experience
Familiarity with 3M360 or similar encoder software
CCDS (Certified Clinical Documentation Specialist) Certification
We are an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to sex, gender identity, sexual orientation, race, color, religion, national origin, disability, protected veteran status, age, or any other characteristic protected by law.