Job description
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Position SummaryUnder general supervision, coordinates and procures appropriate documentation in the medical record of patient care and services to facilitate achievement of high quality, cost effective outcomes. Works collaboratively with physicians and MGMC’s interdisciplinary team to assure medical record documentation accurately reflects the appropriate severity of illness.
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Position Responsibilities
- Identifies appropriate cases (or documentation) for Compliant Documentation Management Program (CDMP) services.
- Conducts an extensive review of all inpatients’ medical records in relation to Medicare Severity DRG Classification Guidelines, to facilitate an accurate representation of the severity of illness of each case.
- Formulates and coordinates clinically credible documentation clarifications with physicians and performs timely follow-ups on those clarifications to ensure appropriate medical record documentation.
- Interacts with physicians, health information management professionals and nursing staff to ensure complete and accurate medical record documentation and manages and resolves discrepancies.
- Coordinates and performs CDMP activities and accurately enters information/ data into CDMP Guide Software.
- Coordinates and maintains the data collection, data transmission, data analysis, and improvement activities associated with CDMP and JATA reporting initiatives.
- Identifies opportunities for documentation/documentation process improvements and implements actions accordingly.
- Assists in the coordination of maintaining compliance related to Joint Commission’s Core Measures and CMS’s public reporting initiatives.
- Assists in the ongoing development, implementation, evaluation and improvement of processes, protocols, clinical standards, and other strategies to effectively provide high quality/safe patient care.
- Remains knowledgeable in and serves as a resource for federal documentation, ICD -9-CM coding, and billing requirements.
- Presents CDMP information and results to various committees and department meetings as needed.
- Maintains regular and reliable attendance.
- Establishes and maintains a means for communicating and collaborating with physicians and other team members.
- Represents department and serves on various committees, teams, and boards as assigned or on a volunteer basis.
- Performs related work as required.
Unit Specific Position Responsibilities -
Qualifications, Knowledge & Experience
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BSN
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Two years of clinical experience in medical/surgical nursing, ICCU or ED.
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Licensed as a Registered Nurse in the State of Iowa.
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Mandatory Reporter training within 90 days of hire and must maintain throughout employment.
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Maintain stroke education per regulatory requirements.
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Knowledge of: medical diagnoses, disease processes, operative procedures and diagnostic testing; psychosocial aspects of health care; patient care processes; inpatient and outpatients services; patient health record format; DRG and managed care reimbursement systems and case mix; Medicare guidelines (Part A & Part B) and federal and state regulations that apply to ICD-9-CM Coding Guidelines and reimbursement.
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Ability to read, write, speak and understand the English language; to demonstrate basic computer skills; to evaluate the appropriateness of diagnoses and procedures; to read and understand chart documentation; to keep current with changes in the medical field; to demonstrate skills and current knowledge in patient assessment.
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Must be able to effectively communicate (verbally and in writing) in a professional and tactful manner with physicians, staff, patients and/or their representatives.
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Must be able to publicly present information to physicians, members of the care team, and others as appropriate.
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Must be self-directed, organized, flexible, and able to adapt to change.
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Must possess critical thinking, problem solving and deductive reasoning skills.
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Must maintain confidentiality of information.
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None specified.
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None Specified
Required Qualifications (Including any licensure, certification, education):Organizational Requirements:Preferred Qualifications:Required Knowledge, Skills & Experience:Preferred Knowledge, Skills & Experience: -
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