ICU Clinical Documentation Registered Nurse RN- Hybrid

JOB SUMMARY Responsible for reviewing medical records to facilitate and obtain appropriate physician documentation for any clinical conditions or procedures to support the appropriate severity of illness, expected risk of mortality, and complexity of care of the patient, by improving the quality of the physicians’ clinical documentation. Exhibits a sufficient knowledge of clinical documentation requirements, MS-DRG Assignment, and clinical conditions and/or procedures. Vaccination Requirements Requires candidates, as applicable and as permitted by law, to obtain and provide confirmation of all required vaccinations and screenings prior to the start of employment. May include but is not limited to: COVID‑19 vaccination, influenza vaccination, and/or any future required vaccines and screenings. Essential Duties or Responsibilities Record Review: Completes initial medical records reviews of patient records within 24-48 hours of admission for a specified patient population to evaluate documentation to assign the principal diagnosis, pertinent secondary diagnoses, and procedures for accurate MS-DRG assignment, risk of mortality and severity of illness; and records in business partner designated CDI tool and/or host medical record system. Follow‑up Reviews: Conducts follow‑up reviews of patients every 24-48 hours or as needed up through discharge to support assigned working MS-DRG assignment upon patient discharge, as necessary. Formulates physician queries regarding missing, unclear, or conflicting health record documentation by requesting and obtaining additional documentation within the health record, as necessary. Collaborates with providers, case managers, nursing staff and other ancillary staff regarding documentation and to resolve physician queries prior to discharge. CDI – Communicates/Completes Clinical Documentation Integrity (CDI) activities and coding issues (lacking documentation, physician queries, etc.) for appropriate follow‑up, provider education and DRG Miss‑Match reconciliation. Assists with provider education, rounding and communication regarding open queries for resolution. Professional Development: Stays current with AHA Official Coding and Reporting Guidelines, CMS and other agency directives for ICD10‑CM and PCS coding. Attends CDI Boot camp, CDI/coding trainings annually and quarterly for inpatient coding. Attends monthly education lecture series (MELS) and all CDI/coding assigned learn‑share modules as well as any additional required CDI education. Assists in training department staff new to CDI. Performs other duties as assigned. Knowledge, Skills, Abilities Demonstrates teamwork and commitment while performing daily duties. Shows initiative and discipline in time management and medical record review. Travel may be required to meet the needs of the facilities. Proficient knowledge of disease pathophysiology and drug utilization. Intermediate knowledge of MS-DRG classification and reimbursement structures. Exhibits critical thinking, problem solving and deductive reasoning skills. Effective written and verbal communication skills. Excellent computer skills including MS Word/Excel. Knowledge of coding compliance and regulatory standards. Excellent organizational skills for initiation and maintenance of efficient workflow. Regular and reliable attendance. Capacity to work independently in facility on‑site setting. Capacity to work independently in a virtual office setting if required for specific assignment. Exhibits flexibility as needed to meet program needs. Understands and communicates documentation strategies. Recognizes opportunities for documentation improvement. Forms clinically, compliant credible queries. Can comply with robust auditing and CDI program monitoring. Applies coding conventions, official guidelines and Coding Clinic advice to health record documentation. Physical Demands Ability to sit for extended periods of time. Ability to stand for extended periods of time. Must be able to efficiently use computer keyboard and mouse. Good visual acuity. Other Must be able to travel as needed, not to exceed 10%. Education / Experience Preferred: Acute Care nursing and/or provider relevant experience. Zero (0) to two (2) years CDI experience. Two (2) plus years’ nursing experience – Medical/Surgical/Intensive Care and/or Case/Utilization Review. Two (2) plus years’ provider experience – Medical/Surgical/Intensive Care and/or Case/Utilization Review. Graduate from a Nursing program, BSN, or graduate program; OR Graduate from Medical Doctor and/or Foreign Medical Doctor Program. Certificates, Licenses, Registrations Active state Registered Nurse license; OR Graduate MD and/or FMD license. Preferred: CDIP or CCDS. EEO Statement Employment practices will not be influenced or affected by an applicant’s or employee’s race, color, religion, sex (including pregnancy), national origin, age, disability, genetic information, sexual orientation, gender identity or expression, veteran status or any other legally protected status. Tenet will make reasonable accommodations for qualified individuals with disabilities unless doing so would result in an undue hardship. Tenet participates in the E‑Verify program. Follow the link below for additional information. E‑Verify: The employment practices of Tenet Healthcare and its companies comply with all applicable laws and regulations. #J-18808-Ljbffr