Clinical Documentation Coordinator- RN, Health Information Mangement, Full Time, Days [remote]

Department: Health Information Management

Address: 1611 NW 12 Ave, Miami, FL 3316

Shift Details: Monday to Friday, Days, Remote [Candidate must reside in Florida]

Jackson Memorial Hospital is the flagship hospital for Jackson Health System and it has been a beacon of medical excellence and community care for more than a century. Throughout its rich and storied history, Jackson Memorial - located in the heart of the City of Miami - has been ground zero for some of the world's greatest medical breakthroughs and important moments in South Florida. We've grown into one of the nation's largest public hospitals, and one of the few that is also a world-class academic medical center with a proud mission and proven success. Jackson Memorial is an accredited, tertiary teaching hospital with 1,500 licensed beds, where nearly every medical specialty is provided by some of the world's most skilled and highly regarded multidisciplinary team of healthcare professionals.

Summary

The Clinical Documentation Coordinator RN is a professional member of the health care team who has a broad clinical knowledge base and understanding of DRG documentation requirements. The 's primary purpose is to facilitate improvement in the overall quality, completeness, and compliance of clinical documentation in the medical record. The facilitates clarification of clinical documentation through extensive medical record review, interaction with physicians, nursing staff, and other members of the patient care team utilizing coding and clinical documentation expertise.

Responsibilities

• Demonstrates knowledge of MS-DRGs, documentation requirements and guidelines.
• Identifies patients to be reviewed based on specific criteria related to diagnosis, clinical condition, cost and/or payer. Performs thorough chart reviews to identify co-morbidities/complications.
• Collaborates with coders to ensure documentation of all known CCs or Major CCs (MCC) on the DRG Coding Abstract.
• Facilitates clarification of clinical documentation to ensure complete and compliant documentation that reflects the level of service rendered and medical necessity.
• Confers with and/or queries attending physicians on a concurrent basis regarding incomplete or vague documentation.
• Facilitates physicians to document all CCs which may effect the assignment of DRGs.
• Conducts follow up reviews of clinical documentation to ensure that points of clarification have been documented in the medical record prior to final coding and billing.
• Reviews clinical issues with the coding staff including working with the coding staff to clarify documentation and identify missed opportunities related to clinical documentation and coding guidelines.
• Validates that medical documentation supports final coding.
• Utilizes the DocMS software program for documentation of reviews.
• Monitors patients progress throughout an episode of care for LOS, based on acuity and regulatory/legislative requirements.
• Liaisons with the Physician Advisor regarding complex cases and established protocols.
• Coordinates and collaborates in regular meetings with key members of the Clinical Documentation team to develop and implement strategies for improvement of clinical documentation and financial outcomes.
• Completes monthly reports and submits in a timely manner.
• Participates in data collection and analysis to identify opportunities for performance improvement related to the operational processes of the Clinical Documentation Program.
• Participates in resource management projects and Utilization Management Committee as assigned. Informs patient/family/proxy/guardian of healthcare benefits/coverage as needed including Medicare appeal rights as applicable.
• Maintains readiness and participates in JHS JCAHO activities.
• Performs MMF/SNEC duties and other hurricane/disaster related activities as assigned.
• Participates in nursing and service excellence activities.
  
  

Experience

• Generally requires 3 to 5 years of related experience.
• At two years of inpatient RN experience is highly preferred
• Previous experience with clinical documentation is also highly preferred.
  
  

Education

• BSN or Bachelor's degree in related field is required. Master's degree is preferred.
  
  

Credentials

• Valid Florida RN license is required.
• American Heart Association Basic Life Support (BLS) and any additional applicable life support certification for Healthcare Providers is required upon hire with at least 6 months validity and maintenance at JHS for the duration of employment. Must meet and maintain valid and current all unit specific and organizational skills/competencies, certifications/licensures, as required by regulatory and/or nursing standard of practice for the specialty.
  
  

Jackson Health System is an equal opportunity employer and makes employment decisions without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, veteran status, disability status, age, or any other status protected by law.