Level I Registered Nurse (RN) - Clinical Document Improvement Specialist Job at Baptist Health System - San Antonio TX, San Antonio, TX

TGpVMFpMbXhwUFRZTURia09QRndSY2Vq
  • Baptist Health System - San Antonio TX
  • San Antonio, TX

Job Description

Job Description

Baptist Health System - San Antonio TX is seeking a Registered Nurse (RN) Clinical Document Improvement Specialist Level I for a nursing job in San Antonio, Texas.

Job Description & Requirements
  • Specialty: Clinical Document Improvement Specialist
  • Discipline: RN
  • Duration: Ongoing
  • 36 hours per week
  • Shift: 12 hours
  • Employment Type: Staff

\n

This position may qualify for a sign-on bonus.  

\n

SUMMARY:

\n

Responsible for improving overall quality and completeness of clinical documentation. Performs concurrent record reviews on all selected admissions and documents findings. Facilitates modifications to clinical documentation to accurately reflect patient severity of illness and risk of mortality through extensive interaction with physicians, case management, nursing staff, other patient care givers and health information management coding staff.    Ensures the accuracy and completeness of clinical information used for measuring andreporting physician and hospital outcomes.    Maintains accurate record of review activities to comply with departmental and regulatory agency guidelines. Understands and complies with policies and procedures related to confidentiality of medical records. Identifies opportunities for interdepartmental and intradepartmental operational improvements. Participates in program related meetings, physician and staff education, staff development, departmental activities and in-service opportunities. Completes established competencies for the position within designated introductory period. Other related duties as assigned.
\n  

 

  • Communicates with the individual physician or medical staff departments to facilitate complete and accurate documentation of the inpatient record
  • query process.
  • Serves as a resource for physicians to help link ICD-10-CM/PCS coding guidelines and medical terminology to improve accuracy of patient severity of illness, risk of mortality, and final code assignment
  • Works in collaborative fashion with the Coders and Case Managers concurrently reviewing the inpatient medical record to assure correct provisional and final DRG assignment
  • Monitors and evaluates effectiveness of concurrent chart review and query outcomes at designated intervals
  • Reports concurrent chart review and query outcomes to hospital departments and committees at designated intervals
  • Performs monthly closed chart reviews and serves on the Chart Documentation Committee
  • Identifies, assist and participates in intradepartmental and interdepartmental special projects involving accuracy of physician documentation and reporting outcomes
  • Utilizes resources efficiently and effectively
  • Maintains safe environment
  • Participates in Performance Improvement activities

Baptist Health System - San Antonio Job ID #2503030968. Posted job title: Specialist Clinical Documentation I (CDI Specialist)

Benefits
  • Health Care FSA
  • Dependent Care FSA
  • Life insurance

Job Tags

Relocation package, Shift work,

Similar Jobs

YMCA of Metropolitan Detroit

Fitness Yoga Instructor Job at YMCA of Metropolitan Detroit

 ...Employee Assistance Program & Retirement Plan General Function Under the guidance of the Member Experience Director, the Yoga Instructor instructs yoga classes in a safe, enjoyable, and positive environment that welcomes people of all skill and fitness levels.... 

RWK Services

Office Cleaner - (Cleveland, Garfield Hts., Independence) Job at RWK Services

 ...immediately for part time cleaning positions in Independence, OH. This individual is responsible for maintaining the cleanliness of the office building through sweeping, mopping, vacuuming, dusting, sanitizing and trash removal. Schedule: Varies - Monday through Friday... 

AIG

Complex Claims Director- AL/GL Field Claims-Lexington and AIG Programs Job at AIG

 ...Complex Claims Director- AL/GL Field Claims-Lexington and AIG Programs Join us as a Claims Complex Director to take on key responsibilities within a world-class claims function. Make your mark in Claims Our Claims teams are the proven problem solvers of choice... 

Kendo Brands, Inc.

Global Marketing Manager - Ole Henriksen (San Francisco) Job at Kendo Brands, Inc.

 ...Join to apply for the Global Marketing Manager - Ole Henriksen role at Kendo Brands,...  ...creative assets internationally; Manage localization process as needed. Collaborate with internal...  ...to prioritize and manage multiple projects. Seniority level ~ Seniority level... 

Robert Half

In-House Counsel Job at Robert Half

 ...relationships, and hands-on involvement across all aspects of our business. Position Overview We are seeking an experienced In-House Counsel to serve as the primary legal advisor to the company and its principals. This role provides strategic and practical legal...