RN - Clinic

Clinical Documentation Specialist RN

The Clinical Documentation Specialist RN is responsible for utilization management activities. This includes evaluating the appropriateness and medical justification of health services. The position focuses on researching, developing, and communicating the implementation of medical policies. It also involves facilitating Medical Policy Committee work. The role is accountable for providing medical treatment reviews, case management, and treatment interventions. These interventions aim to promote cost-effective medical care and support early return to work in workers' compensation cases. In addition, the position identifies and coordinates opportunities for continuous quality improvement projects. It includes provider profiling, benchmarking, and provider education. The Clinical Documentation Specialist RN will diffuse conflicts and negotiate solutions in sensitive situations. They will relate quality of care with cost-effectiveness and develop medical management strategies to achieve this objective. The role requires researching, integrating, and analyzing data from multiple sources. It necessitates synthesizing problem statements and issues and seeking input from various stakeholders. The Specialist will interact with multiple departments and providers to solve problems and create solutions that enhance efficiency and quality of care. Managing healthcare resources while maintaining positive relationships with workers, providers, and insurers is essential. Reprioritizing work effectively in a fast-paced environment is a key responsibility. Additionally, identifying potential liability situations and implementing strategies to minimize risk is crucial. The Clinical Documentation Specialist RN identifies the need for developing medical policies. They will establish and maintain a process for timely updates of criteria and medical policies. Performing prospective reviews of health service requests using current policies and criteria is a requirement. Consultation with physicians or medical directors regarding health services and appropriateness of provided services is essential. Identifying and researching quality of care issues is part of the role. The specialist will act as a liaison with health plan utilization management and care management teams. Retrospective reviews of treatments to ensure adherence to established protocols will be conducted. Identifying new or existing program components needing development will be part of the job responsibilities. The Specialist will provide data collection and analysis of provider profiling data and implement necessary interventions. They will provide medical consultation to non-medical staff when necessary and track disputed surgical cases. Applying sound medical principles in case management and decision-making is expected. The role includes assisting in responding to general customer service inquiries and accurately coding medical diagnoses. Maintaining timely and accurate reviews of requests for medical services is crucial. Participating in team building and committee work will be an essential part of the position. The Specialist will actively seek opportunities to improve skills through ongoing education and networking. Reviewing provider documentation and assisting with quality improvement programs is part of the role. Ensuring confidentiality and protection of privileged information is essential. Participation in quality committees to assign cases for review and initiate quality improvement changes is also expected.