RN DOCUMENT REVIEWER

JOB SUMMARY Working under the supervision of the department Director/Manager and in conjunction with the supervisor, the RN Document Reviewer reviews documentation to ensure accuracy in clinical presentation and facility billing. They work with staff to ensure accurate and timely documentation in conjunction with auditing process. The nurse reviewer practices within the framework of the Wyoming Nurse Practice Act and American Nurses Association (ANA) professional standards and the guidelines of the department#s nursing specialty organization. Designs, implements, maintains, and analyzes data from clinical informatics systems. Implements electronic health record (EHR) systems, computerized physician order entry systems, or any other relevant health information systems. Analyzes data produced by these systems to identify trends and areas for improvement and to ensure systems are functioning properly. Evaluates and recommends improvements to systems. May provide staff training on new or updated systems. ESSENTIAL FUNCTIONS Demonstrates competency in the duties of Registered Nurse Reviews the complete medical record for documentation of assessment, procedures and interventions. Actively pursues obtaining accurate data entry at the time of patient visit Works with medical and nursing staff in a timely manner to clarify documentation issues related to suggested coding guidelines and patient charges. Works with EMR system administration as required to address system needs Identifies staff training needs and participates with manager and EMR administrator to assist with training Institutes charges in a timely matter Maintains current knowledge in clinical practices, may be dependent on area assigned to Actively participates in hospital committees, CQI teams, and Quality Improvement Program. May be required to work on other nursing units according to distribution of staff and patients. Complies with the hospital#s Corporate Compliance Program including, but not limited to, the Code of Conduct, laws and regulations, and hospital policies and procedures. Must be free from governmental sanctions involving health care and/or financial practices. Performs other duties as assigned JOB QUALIFICATIONS Education Graduate of an accredited school of nursing. Licensure Current RN license in the state of Wyoming Certifications required See Cardiopulmonary Resuscitation Certification Policy and Certifications/Education Requirements Policy. Experience 2 years RN experience required. May be required to attend training in coding upon hire Knowledge, Skills, and Abilities Strong knowledge of clinical practice standards required. Strong knowledge of EMR required. Experience in documentation review or auditing preferred Computer skills. Computer literate with good keyboarding skills. Eye-hand coordination, manual and finger dexterity. Ability to learn and utilize alphabetical and terminal digit filing systems. Ability to develop positive interaction with patients, patient families, physicians and staff in order to effectively care for the patients. Ability to lift and/or maneuver objects weighing 40 pounds or less in the assessment and implementation of patient care. Requires shift work. Must be able to assess a patient#s condition, formulate a plan of care, select appropriate interventions, and evaluate patient response to care/treatment and to explain/teach patients about their condition/recovery. Requires higher level of mental faculties accompanied by short- and long-term memory. Ability to function in stressful situations.