Address
Form of work- POSITION PURPOSEPerforms concurrent Clinical Documentation review to promote complete capture of documentation needed to accurately code level of clinical service and patient acuity. Works collaboratively with physicians and coders.
- MINIMUM EDUCATION REQUIRED
- Associate Degree in Nursing
- MINIMUM EXPERIENCE REQUIRED
- 3 - 5 Years
- LICENSES / CERTIFICATIONS REQUIRED
- Licensure to be eligible to practice as a Registered Nurse (RN) in the State of Wisconsin.
- CCS (Certified Coding Specialist) preferred.
- KNOWLEDGE, SKILLS & ABILITIES REQUIRED
- Ability to read, write, hear, speak, and comprehend the English language.
- Strong understanding of pathophysiology, disease processes, and diagnostic testing results.
- General understanding of ICD coding conventions and DRG methodology.
- Strong MS Word and Excel skills.
- Strong organizational, analytical, communication, and interpersonal skills.
- Ability to work independently as well as part of a team.
- Previous acute care clinical experience preferred.
- PRINCIPLE ACCOUNTABILITIES AND ESSENTIAL DUTIES
- Performs concurrent medical record review of defined bedded patients, documents provisional DRG, and documents potential working DRGs up until patient discharge.
- Facilitates necessary Clinical Documentation in the medical record through verbal and written communication with clinicians.
- Evaluates Clinical Documentation patterns to identify areas for improvement, identifies changes which will proactively collect required documentation, and develops reports to monitor program success and opportunities for concentrated focus.
- Educates patient care team members regarding Clinical Documentation requirements and coding guidelines and provides feedback on patient care team members’ Clinical Documentation.
- Works collaboratively with other disciplines to achieve the most precise and reflective final coding. #cb
Location: Froedtert South, Inc. · MEDICAL RECORDS
Schedule: Full-time, Days, 80
