Inpatient Clinical Documentation Specialist RN

This position may be eligible for a $3000 sign-on bonus, relocation assistance and tuition loan repayment

The Clinical Documentation Specialist - Inpatient will conduct concurrent review of clinical documentation in the inpatient medical record with the goal to obtain the most accurate and complete physician documentation that appropriately supports the severity of a patient’s illness, mortality risk, and proper reimbursement. Responsible to query physicians and other caregivers via written and/or verbal communications for clarification of clinical documentation. He/she works collaboratively with the coding and compliance departments to ensure appropriate final DRG assignments and CC/MCC capture. In collaboration with the RN CCs team will Provides ongoing education related to documentation requirements and opportunities to all providers requirements and opportunities to all providers. Will conduct concurrent and retrospective medical record review for defined patient populations to identify opportunities to improve accuracy of practitioner documentation.

Essential Job Functions

• Supports and models behaviors consistent with Billings Clinic’s mission, vision, values, code of
• Meets all mandatory organizational and departmental requirements.
• Maintains competency in all organizational, departmental, and outside agency
• Performs admission reviews within 24 to 48 hours for patient populations to facilitate
• Conducts ongoing reviews of physician/provider and other clinical documentation, lab results,
• Queries physicians and non-physician providers verbally and in writing daily according to
• Validates that follow-through of accurate documentation has occurred and reports appropriately.
• In collaboration with physicians and coding specialists, identifies and records principal diagnosis,
• Provides education to physicians in a one to one setting regarding documentation specificity and the
• Utilizes medical staff established criteria for complications to assist in appropriate documentation
• Collaborates with clinical coordinator and RN CCS with the coding staff and provides clinical
• Acts as a liaison between coding staff and physicians to resolve questions about documentation and/or coding.??
• Reviews previous Billings Clinic encounters and supporting information in the concurrent electronic
• Ensures appropriate documentation exists for any conditions that were present on admission (POA).
• Participates in process improvement activities with department leadership, department team members, and inter-departmental team members.
• Identifies needs and sets goals for own growth and development; meets all mandatory organizational and departmental requirements.
• Maintains competency in all organizational, departmental, and outside agency environmental, employee, or p patient safety standards relevant to job performance.
• Performs other duties as assigned or needed to meet the needs of the department/organization