DEFINITION:

Is responsible for improving the overall quality and completeness of clinical documentation. Facilitates modifications to clinical documentation through extensive concurrent interaction with physicians, nursing staff, other patient caregivers and Health Information Management coding staff to support appropriate reimbursement and clinical severity is captured for the level of service rendered to all patients with a DRG based payer. Supports timely, accurate and complete documentation of clinical information used for measuring and reporting physician and hospital outcomes. Educates all members of the patient care team on an ongoing basis.
EDUCATION:

Graduate of an accredited school of nursing or accredited Health Information Management program .
REGULATORY REQUIREMENTS (IF APPLICABLE):

Authorized to practice as a Registered Nurse or Licensed Practical Nurse in the state of Oklahoma or a Registered Health Information Administrator (RHIA).
MINIMUM QUALIFICATIONS:

RN/LPN with at least (2) years of experience in nursing care or experience in case management; prefer one year of coding experience.

RHIA with at least one (1) year of inpatient coding experience or equivalent clinical experience.
PREFERRED QUALIFICATIONS:

Working knowledge of ICD-10-CM coding principles and guidelines or willingness to obtain.

Working knowledge of federal, state and payer-specific regulations and policies pertaining to documentation, coding, and reimbursement or willingness to obtain.

Demonstrates critical thinking skills, communication verbal and written, mathematical and analytical skills and have a professional presentation, ability to work independently, set priorities, and manage work accurately and timely.

Must have basic computer skills and proficient in Microsoft Office products. (Excel, Word, ect)

Able to maintain confidential information.