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Registered Nurse Clinical Documentation Specialist in Kenosha, Wisconsin at Froedtert South, Inc.

NewJob Function: Medical
Froedtert South, Inc.
Kenosha, Wisconsin, 53143, United States
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Job Description

Registered Nurse Clinical Documentation Specialist

  • POSITION PURPOSE
    • Performs 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.
    • 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.

Job Location

Kenosha, Wisconsin, 53143, United States

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