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Form of workDescription
Job Summary
Analyzes the medical record for clinical status of the patient, current treatment plan and care provided on admission and throughout hospitalization to identify potential gaps in physician documentation; tracks progress of documentation improvement and works collaboratively with the healthcare team to facilitate documentation within the medical record that accurately reflects the patient's condition, severity of illness, risk of mortality, services rendered and medical necessity of resources used.
Minimum Qualifications
Education
B.S. Degree in nursing preferred.
Licensure/
Certification
North Carolina Registered Nurse Licensure.
Experience
Minimum of 2 years' experience in CDS role in an acute care facility required.
Minimum of 3 years' experience in acute care (hospital) setting required. Medical/Surgical or critical care experience preferred.
Knowledge, Skills and Abilities
Clinical documentation knowledge as it relates to DRGs, POA, MCCs and CCs.
Understanding of coding classification systems (ICD-9, ICD-10, CPT, HCPCS).
Clinical knowledge to read and analyze a patient's health record.
Clinical understanding of pharmacology, pathophysiology, labs, radiology and disease processes.
Strong analytical skills.
Ability to collaborate and communicate with physicians, nursing, and other patient care teammates.
Ability to read, write and communicate effectively in English.
Proficient with MS Office and able to learn new software rapidly. Experience with EPIC EMR software preferred.
Become part of an inclusive organization with over 40,000 diverse employees, whose mission is to improve the health and well-being of the unique communities we serve.
Summary:
WAYNE
Responsibilities:
WAYNE
Other information:
MR-546
01.8710.MR-546
Job Details
Legal Employer: Wayne Health
Entity: Wayne UNC Health Care
Organization Unit: Health Information Mgmt
Work Type: Full Time
Standard Hours Per Week: 40.00
Work Assignment Type: Remote
Work Schedule: Day Job
Location of Job: WAYNE MED
Exempt From Overtime: Exempt: Yes
