Registered Nurse RN - Clinical Documentation Improvement Specialist - CDIP ACDIS AHIMA - Mon - Fri 8:00am - 5:00pm - Remote

Northeast Georgia Health System (NGHS) is a non-profit on a mission of improving the health of our community in all we do. Our team cares for more than 1 million people across the region through five hospitals and a variety of outpatient locations. Northeast Georgia Medical Center (NGMC) has campuses in Gainesville, Braselton, Winder, Dahlonega and Demorest – with a total of more than 850 beds and more than 1,200 medical staff members representing more than 60 specialties. Learn more at www.nghs.com.

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 to ensure that appropriate reimbursement is received for the level of service rendered to all patients with a DRG based payer (Medicare, Blue Cross, other payors as determined by CDI departmental goals). 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.

Demonstrates aptitude in critical care or medical-surgical nursing Must demonstrate excellent observation skills, analytical thinking, problem-solving abilities, and excellent written and verbal communication by organizing work priorities and following standard of work Working knowledge of DRG coding optimization strategies and clinical documentation requirements are helpful Demonstrates interpersonal skills including professionalism practicing positive approaches to the position The position requires computer skills and the ability to be self-directed Familiar with ICD10 coding conventions, anatomy and physiology, medical terminology, MSDRG reimbursement, coding software (preferably 3M 360 Encompass) Leadership skills are required Maintains requirements contained in Remote Agreement or forfeit the opportunity Essential Tasks and Responsibilities: Improves the overall quality and completeness of clinical documentation by performing admission / continued stay reviews using the Compliant Documentation Program Management (CDMP) guidelines. Facilitates modifications to clinical documentation to ensure that appropriate severity of the patient is documented and to ensure appropriate reimbursement is received for the level of service rendered to all patients with a DRG based payer (Medicare, Blue Cross and others as determined by CDI program goals) Conducts on-going follow-up reviews to ensure points of clarification have been recorded in the patient's medical record using department standard work to set workflow priority and scheduling.. Works with Physicians concurrently, during the patient's stay, to educate and receive specific documentation pertinent to all requirements in question. Refers questionable quality, patient safety indicators, and utilization concerns to CDI Director, nursing and case management as indicated Writes queries to provide professional clinical inquiry about missing documentation (clinical indicators, diagnoses, or more descriptive) for conversion to codable terms following compliant, non leading format. Monitors the documentation against "core measure" quality indicators and addresses non-compliance documentation with Physicians and other appropriate staff. Interacts on a regular basis with Physician, nursing and case managers to ensure continuity of documentation. Works collaboratively with the coding staff to assign the "working" DRG to contribute for IDT Rounds. Processes all discharges by updating the DRG worksheet to reflect changes in patient status, procedures and/or treatments and concurs with the attending Physician to finalize diagnoses. Maintains a leadership role to ensure specific and compliant documentation is achieved recognizing its use in quality measures and reporting medical center and Physician outcomes. Educates various customer audiences on clinical documentation opportunities, coding, reimbursement and performance methodologies. Ensures documentation is meeting "medical necessity" for specific level of care and that services provided to the patient has a reasonably beneficial effect; refers cases to Utilization Review as indicated. Demonstrates a working knowledge of the DRG system and coding guidelines to facilitate recovery of appropriate payments for services rendered. Utilizes results of DRG analysis to have on-going dialogue with Physicians, nurses, coders, and case managers, to improve overall knowledge and performance. Participates in efforts to contain cost and/or generate revenue. Submits written ideas for reducing cost or adding revenue. Organizes and performs work effectively and efficiently by achieving daily reviews as assigned. Maintains and adjusts schedules to meet team performance and is willing to change workload or assignments as indicated. Meets assigned deadlines and departmental productivity standards. Assists with special projects as needed and all other duties as assigned. Maintains requirements in Remote Agreement in order to retain work from home opportunity. Work collaboratively with CDI team members to complete daily work of the team.