Reviews inpatient medical records documentation for reimbursement, severity of illness, risk of mortality and identifies opportunities for improving the quality of medical record documentation and confers with the caregiver regarding additional documentation required. Collects statistics from the reviews and maintains accurate records to document costs and benefits. Facilitates and enhance the coding and DRG between physician and coding staff process assignment.
- ADN required; BSN preferred
- Basic computer skills in word processing and spreadsheet utilization.
- Excellent written and verbal communication skills.
- Proficient in computer use (desktop and/or laptop).
- Demonstrates basic knowledge regarding HIM coding standards.
- Analytic skills necessary to accurately assess patient medical records.
- Excellent interpersonal skills and ability to work on a team in order to influence physician documentation processes.
- Ability to be flexible and adjust to workload/assignment changes and interruptions.
- ** May be asked to travel to other CHRISTUS Facilities (Santa Rosa and Spohn Regions).
- Minimum of 5 years recent experience in an acute care setting in a clinical nursing field required.
- Prior experience in clinical documentation improvement, utilization review/management, discharge planning, quality management, case management or coding preferred.
C. Licenses, Registrations, or Certifications
- Current license as a Registered Nurse in the State of Texas required