Current Employees:

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Primary Location

Rapid City, SD USA

Department

RCH Health Information Management

Scheduled Weekly Hours

40

Starting Pay Rate Range

$68,224.00 - $85,280.00

(Determined by the knowledge, skills, and experience of the applicant.)

Job Summary

Utilizes clinical expertise to evaluate medical record chart documentation to ensure the clinical documentation reflects the level of service rendered to patients is complete and accurate. Extensive interaction with physicians and multidisciplinary team members required for facilitating modifications to the overall quality and completeness of the medical record documentation through ongoing education and monitoring. Adheres to general hospital and regulatory agency standards and promotes a cooperative work environment by utilizing communication skills, interpersonal relationships and team building.

Monument Health offers competitive wages and benefits on qualifying positions. Some of those benefits can include:

*Supportive work culture

*Medical, Vision and Dental Coverage

*Retirement Plans, Health Savings Account, and Flexible Spending Account

*Instant pay is available for qualifying positions

*Paid Time Off Accrual Bank

*Opportunities for growth and advancement

*Tuition assistance/reimbursement

*Excellent pay differentials on qualifying positions (extra pay for working evening, nights or weekends)

*Flexible scheduling

Job Description

Essential Functions:

• Educates all internal customers on clinical documentation opportunities and coding and reimbursement issues.
• Facilitates appropriateness of clinical documentation through extensive interaction with physicians, nursing staff and coding specialists to ensure that documentation reflects the appropriate level of service rendered to all patients with a DRG based payor.
• Supports ongoing clinical documentation education for new staff, including new care managers, coders, physicians, residents, allied health professionals and nursing staff.
• Improves the overall quality and completeness of clinical documentation by performing concurrent and retrospective reviews for specific patient populations to ensure that the resources consumed, risk of mortality, and severity of illness are accurately reflected in the medical record.
• Inputs case specific information into database for each case reviewed; reviews clinical issues with Coding Specialists to ensure points of clarification have been recorded in the Medical Record.
• Reviews clinical issues and coding concerns with the coding specialists to support appropriate DRG assignment.
• Facilitates modifications to the clinical documentation, through the approved query process(es), and provides follow of non-participating providers through the appropriate channels.
• Maintains positive open communication with physicians, interdisciplinary care team members, coding specialists and department director.
• Performs follow up on incomplete physician queries to obtain and answer while the patient is still in house.
• Attends scheduled meetings as requested ad provide education where appropriate.
• Assist with reporting and tracking as requested.
• All other duties as assigned.

Additional Requirements

Required:
Education - Completion of a nursing education program that is approved by a board of nursing
Certification - Registered Nurse (RN) - South Dakota Board of Nursing

Preferred:

Education - Bachelors degree in Nursing

Certification - Certified Clinical Documentation Specialist (CCDS) - Association of Clinical Documentation Improvement Specialists and/or Clinical Documentation Improvement Professional (CDIP) - American Health Information Management Association (AHIMA)
Experience - 3+ years of Healthcare Experience

Physical Requirements:
Light work - Exerting up to 20 pounds of force occasionally, and/or up to 10 pounds of force frequently, and/or a negligible amount of force constantly to move objects.

Job Category

Revenue Cycle

Job Family

Health Information Management

Shift

Employee Type

Regular

10 Monument Health Rapid City Hospital, Inc.

Make a difference.  Every day.

Monument Health is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, or protected Veteran status.