CLINICAL DOCUMENTATION SPECIALIST / 40 HOURS / VARIABLE DAY SHIFT - BWH - CLINICAL DOCUMENTATION IMPROVEMENTS

Brigham & Women's Hospital(BWH) - Boston, MA (23 days ago)4.2


Nursing at Brigham and Women’s Hospital is known for their excellent clinical practice and for keeping patients and their families at the center of all they do. We understand that great care is shaped by relationships with patients and their families. That’s why we’re committed to knowing our patients on a deeper level — not just as patients, but as individuals — to ensure that they, and their families, feel known and cared for.

As BWH, we proudly work together with a spirit of inquiry and a deep commitment to providing the highest quality, evidence-informed and theory-guided care in an inclusive environment. We work each day to achieve our vision — to provide excellent care to patients and families, with the best staff, in the safest environment.

Just as we have been able to reinvent health care, we have also transformed health care careers. Whether measured in terms of lives saved, awards earned, or the personal satisfaction of stretching your talents – a career with BWH is unlike any other in the health care field. Here you'll find a workplace where collaboration and teamwork are the norm, not the exception – physicians, nurses, technicians, staff and management form a close-knit bond, based on mutual respect and devotion to our patients. If you want an enormously fulfilling career, there’s no better place to be.

PRINCIPAL DUTIES AND RESPONSIBILITIES:
Working collaboratively with medical, nursing and ancillary staffs to improve the quality of chart documentation that assures appropriate DRG classification to accurately reflect patient severity of illness and risk of mortality.
Performing initial case reviews and appropriate number of follow-up reviews based on program standards
Using clinical insight and judgment of clinical findings to assess clinical documentation for improvement opportunities.
Following-up with the physician responsible for care of the patient, via the query process, for clarification of clinical significance and appropriate documentation.
Assigning the DRG based on coding guidelines/regulations issued by AHA (Coding Clinic), and CMS.
Maintaining professional competency by keeping abreast of new coding issues and guidelines. Attends classes and meetings as assigned. Reviews professional CDI and coding literature regularly.
Interpreting clinical information in medical record, evaluates medications, vital signs, surgical outcomes, etc. to identify potential documentation improvement opportunities.
Identifying opportunities for physician education to improve medical record documentation for severity of illness.
Contributing to and participating in educational efforts and activities.
Participating in seminars, in-service/educational efforts and activities sponsored by professional associations at the local, state, and national levels. Fulfilling continuing education requirements to maintain credential/license status.
Communicating verbally, via email or writing with physician to obtain/clarify more specific documentation of the principal diagnoses, co- morbidities and complications. Requesting clarification of existing documentation that most accurately reflects patient severity.
Communicating cooperatively as needed with coding specialists
Meeting with the lead physician advisors, as needed.
Communicating effectively with medical staff and Coding Quality Manager (as necessary) to acquire, interpret, and transmit accurate diagnostic and procedure information for billing.
Keeping Program Director informed of potential and/or actual problems identified during the review process, concurrent progress and operation of program.
Communicating tactfully and respectfully, always maintaining professional communication.
Other duties as assigned

Qualifications

Registered Nurse with a current license in the state of Massachusetts.
Minimum of 6 years of acute medical/surgical care nursing is desired.
Clinical Documentation Improvement in ICD-10 experience is required.
Certification in Clinical Documentation is preferred.
Experience with APR DRG's preferred.
Advanced computer functions, data entry, knowledge of working in data base is required.
Graduate of an approved school of nursing with current registration in MA. For newly licensed nurses a BSN is required
EEO Statement
Brigham and Women’s Hospital is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, creed, sex, sexual orientation, gender identity, national origin, ancestry, age, veteran status, disability unrelated to job requirements, genetic information, military service, or other protected status.

Primary Location
: MA-Boston-Boston - BWH Main Campus
Work Locations
:
Boston - BWH Main Campus
75 Francis St
Boston 02115
Job
: Nursing-Other
Organization
: Brigham & Women's Hospital(BWH)
Schedule
: Full-time
Standard Hours : 40
Shift
: Day Job
Employee Status
: Regular
Recruiting Department : BWH Nursing / Patient Care Services
Job Posting
: Oct 22, 2018