Responsible for review of all inpatient medical records, analyze documentation of clinical diagnoses using ICD 10 criteria. Goal to identify conflicting diagnoses, gaps in clinical documentation, unspecified diagnoses, missing diagnoses and use clinical validation to clarify these diagnoses with providers.
Maintain chart integrity with accurate and specific diagnoses. Maintain current knowledge of changes in diagnosis requirements for specificity around ICD changes.
Outpatient medical review as indicated with same goals of accuracy and specificity and ICD 10 criteria. Educate and support the need to document for risk stratification in the primary care offices.
Education of ICD 10 specificity and documentation requirements for attending and resident physicians, medical students, advanced practice nurses and clinical nurses.
Resource for hospital coding staff re: clinical knowledge of conditions and diagnosis specificity.
Collaborate with coding integrity and physician abstractors in delivering documentation education to providers including education of risk stratification, chronic conditions, and appropriate documentation to support billing.
Support IT development of templates, databases, other documentation tools in conjunction with patient care team. Support CI/QI efforts within the hospital, assisting with gathering of HAI/HAC and research documentation.
Monitor and support improvement of patient problem lists in EHR for both inpatient and outpatient settings
Requirements
Bachelor’s Degree required
Extensive knowledge of medical terminology, anatomy, physiology, pharmacology and disease processes
Registered Nurse preferably with Pediatric nursing and/or CDI experience
Minimum Of 5 Years Experience In Pediatric Nursing
Licensed registered nurse active and unrestricted in the State of Delaware for NCH DE and/or the state of Florida for NCH FL
CDI certification and/or coding certification preferred.PDN-9a3ceb61-4124-4efe-b21e-262c961d0557
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