RN - CLINICAL DOCUMENTATION SPECIALIST ID-1649

November 28, 2024

RN2/Clinical Documentation Specialist

Responsible for improving the overall quality and completeness of clinical documentation. Facilitates modifications to clinical documentation through extensive interaction with physicians, nursing staff, other patient caregivers, and medical records coding staff.

Ensures that appropriate reimbursement is received for the level of service rendered to all patients with a DRG or APDRG based payer. Ensures the accuracy and completeness of clinical information used for measuring and reporting physician and medical center outcomes. Educates all members of the patient care team on an ongoing basis.

Facilitates modifications to clinical documentation to ensure that appropriate reimbursement is received for the level of service rendered to all patients with a DRG or APDRG based payer.

Demonstrates knowledge of DRG and APDRG payer issues, documentation opportunities, clinical documentation requirements, and referral policies and procedures.

Improves the overall quality and completeness of clinical documentation by performing admission/continued stay reviews using Compliant Documentation Program Management® (CDMP®) software guidelines.

Ensures the accuracy and completeness of clinical information used for measuring and reporting physician and medical center outcomes.

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Process discharges by updating the Worksheet to reflect any changes in status, procedures/treatments, and conferring with physician to finalize diagnoses.

Educates all internal customers on compliant 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 DRG or APDRG.

Participates in QA studies as assigned for Quality Core Measures, Patient Safety and Hospital Acquired Conditions, referring quality issues to appropriate resources.

Assists with management of CDMP Trak©

A higher degree of healthcare.

All across UW Medicine, our employees collaborate to perform the highest quality work with integrity and compassion and to create a respectful, welcoming environment where every patient, family, student and colleague is valued and honored.

Harborview Medical Center is a level one adult and pediatric trauma center as well as regional burn center for a four state region; a teaching and research hospital for the University of Washington; and a public/safety-net hospital for our diverse community.

Harborview Medical Center was awarded Magnet recognition by the American Nurses Credentialing Center (ANCC) for our excellence in patient care for the community and populations we serve.

This recruitment offers a $10,000 Recruitment Incentive to eligible new employees joining UW Medicine.

Requirements:
• Current license to practice as a Registered Nurse in the State of Washington (or applicable multistate RN license).
• RN with recent experience in a hospital setting. Critical Care and ICU experience desirable.
• Excellent observation skills, analytical thinking, problem solving, good written and verbal communication skills.
• Utilization Management and/or Clinical Documentation Program experience preferred.
• Coding experience and/or certification preferred.
• Excellent observation skills, analytical thinking, problem solving, good written and verbal communication skills.
• Excellent interpersonal skills, professional, team player, with strong interpersonal skills and a positive personality.

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