Cln Documentation Spec Nurse

J  o  b    D  e  s  c  r  i  p  t  i  o  n

JOB INFORMATION

Effective Date:

12/1/2023

Entity:

Wisconsin

Job Code:

300108

Job Title:

Cln Documentation Spec Nurse

FLSA Exemption Status:

Exempt

Management Level:

Individual Contributor

JOB SUMMARY

The Clinical Documentation Specialist Nurse (RN-CDS) is an advisor to clinicians regarding complete and accurate inpatient documentation. The incumbent functions as a liaison between clinicians and coders with the goal of creating mutual understanding of the many uses of medical record documentation. The Specialist functions as an expert source for information regarding the impact of documentation on patient care, quality of care metrics, accurate reimbursement, risk of mortality/severity of illness indicators, and correct reimbursement. Under the direction of the Clinical Documentation Integrity Supervisor, The RN-CDS conducts concurrent reviews of inpatient medical records in accordance with state, federal and other accrediting agencies.

The RN-CDS utilizes strong clinical knowledge, official coding guidelines, in depth risk adjustment understanding, and standards of compliance to identify clinical documentation opportunities and to achieve results.

ESSENTIAL DUTIES

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Facilitates appropriate clinical documentation to support the severity of illness and complexity of care rendered to patients

•

Concurrently reviews records to identify unclear, ambiguous or inconsistent documentation. Initiates verbal and/or written physician queries and conducts necessary follow up.

•

Collaborates with coding staff on retrospective medical record review for severity, accuracy and quality issues

•

Advises clinicians on the value of reliable, precise, complete, consistent, clear and timely documentation. Advises clinicians on the impacts of quality documentation on patient care and clinical data base integrity.

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Collaborates with clinicians on the process by which clinical documentation is translated into codes

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Counsels clinicians on the effects of translation on physician and hospital quality outcome measures and hospital financial performance

•

Tracks and trends documentation integrity metrics. Assigns “working” values for severity, risk of mortality and DRG (MS and APR) and tracks potential changes with documentation improvement. Participates in the development of reports documenting the impacts of the program.

•

Identifies improvement opportunities for system functionality; creates efficiencies and communicates opportunities for improvement

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Assures record consistency among admission order, record description of medical necessity and patient status

•

Functions as an expert source for information regarding the impact of documentation on patient care, severity of illness, DRG assignment and quality of care/risk adjustment metrics.

As needed, additional responsibilities reasonably within the scope of duties and physical requirements may be assigned.  ALL DUTIES AND REQUIREMENTS MUST BE PERFORMED CONSISTENT WITH THE UW HEALTH PERFORMANCE STANDARDS AND RESPECT FOR PEOPLE COMMITTMENTS.

X

Non-Clinical

JOB REQUIREMENTS

Associate's Degree

in Registered Nursing

Required

Bachelor's Degree

of Science in Nursing (BSN)

Preferred

3 years

nursing, case management, utilization review or quality resources experience in an acute care setting

Required

3 years

Clinical Documentation Integrity experience highly desirable

Preferred

5 years

nursing, case management, utilization review, or quality resources experience in an acute care setting

Preferred

Licensed as a Registered Nurse (RN) in the State of WI or holds a license issued by a jurisdiction that has adopted the nurse licensure compact

Upon Hire

Required

Certified Clinical Documentation Specialist

Preferred

or

Certified Documentation Improvement Practitioner

Preferred

LICENSE, CERTIFICATIONS, AND REGISTRATIONS MUST BE MAINTAINED PER UW HEALTH POLICY. 

•

Excellent interpersonal skills

•

Knowledge of, but not limited to, current coding guidelines and methodologies, MS-DRG, APR-DRG, HCCs; ICD-10-CM/PCS coding guidelines and conventions.

•

Demonstrate extensive clinical knowledge necessary to meet performance standards in the position and provide clinical documentation guidance to peers and providers

•

Strong organization and analytical thinking skills

•

Proficient with Microsoft Office applications (Outlook, Word, Excel, PowerPoint)

•

Demonstrates critical thinking skills, able to assess, evaluate, and teach.

•

Self-motivated and able to work independently without close supervision. Strong communication skills (interpersonal, verbal and written)

•

Ability to work independently and think creatively

•

Must be able to work flexible hours which may include weekends as required to meet business needs.

•

Willingness to seek CCDS or CDIP certification

•

Familiarity with the external reporting aspects of healthcare

•

Familiarity with the business aspects of healthcare, including prospective payment systems

PHYSICAL REQUIREMENTS/WORKING CONDITIONS

☒

Sedentary: Ability to lift up to 10 pounds maximum and occasionally lifting and/or carrying such articles as dockets, ledgers and small tools. Although a sedentary job is defined as one, which involves sitting, a certain amount of walking and standing is often necessary in carrying out job duties. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Up to 10#

Negligible

Negligible

☐

Light: Ability to lift up to 20 pounds maximum with frequent lifting and/or carrying of objects weighing up to 10 pounds. Even though the weight lifted may only be negligible amount, a job is in this category when it requires walking or standing to a significant degree.

up to 20#

Up to 10# or requires significant walking or standing or requires pushing/pulling of arm/leg controls.

Negligible or constant push/pull of items of negligible weight

☐

Medium: Ability to lift up to 50 pounds maximum with frequent lifting and/or carrying objects weighing up to 25 pounds.

20-50#

10-25#

Negligible-10#

☐

Heavy: Ability to lift up to 100 pounds maximum with frequent lifting and/or carrying objects weighing up to 50 pounds.

50-100#

25-50#

10-20#

☐

Very Heavy: Ability to lift over 100 pounds with frequent lifting and/or carrying objects weighing over 50 pounds.

Over 100#

Over 50#

Over 20#

Other - list any other physical requirements or bona fide occupational qualifications not indicated above:

Over 50 lbs.

UW Health does not require, nor does it expect that its employees lift more than 50 lbs unassisted. Objects in excess of 50 lbs should be lifted or moved with mechanical means or through a team lift. Employees in patient care areas are expected to utilize mechanical lifts and adhere to the "Use of Mechanical Lifts (Liko)" policy in the Patient Services Policy and Procedure Manual.

Note: The purpose of this document is to describe the general nature and level of work performed by personnel so classified; it is not intended to serve as an inclusive list of all responsibilities associated with this position.

THE EMPLOYEE MUST BE ABLE TO COMPLETE ALL PHYSICAL REQUIREMENTS OF THE JOB WITH OR WITHOUT AN APPROVED ACCOMODATION. Note: The purpose of this document is to describe the general nature and level of work performed by personnel so classified; it is not intended to serve as an inclusive list of all responsibilities associated with this position.