As one of the nation’s leading pediatric health care systems, Nemours is committed to providing all children with their best chance to grow up healthy. We offer integrated, family-centered care to more than 300,000 children each year in our pediatric hospitals, specialty clinics and primary care practices in Delaware, Florida, Maryland, New Jersey and Pennsylvania. Nemours strives to ensure a healthier tomorrow for all children – even those who may never enter our doors – through our world-changing research, education and advocacy efforts. At Nemours, our Associates help us deliver on the promise we make to every family we have the privilege of serving: to treat their child as if they were our own.
Clinical Documentation Specialist RN
Extensive knowledge of medical terminology, anatomy, physiology, pharmacology and disease processes
Responsible for review of all inpatient medical records, analyze documentation of clinical diagnoses using ICD 10 criteria. May also be required to review outpatient charts. Goal to identify conflicting diagnoses, gaps in clinical documentation, unspecified diagnoses, missing diagnoses and clarify these diagnoses with providers.
Maintain chart integrity with accurate and specific diagnoses
Outpatient medical review as indicated with same goals as well as updating problem list and maintaining accuracy and integrity
Education of ICD 10 specificity for attending and resident physicians, medical students, advanced practice nurses and clinical nurses.
Resource for HIM coding staff re: clinical knowledge of conditions and diagnosis specificity.
Collaborate with coding integrity and physician abstractors in delivering documentation education to providers
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
Review inpatient medical records within 2 days of admission for documentation opportunities and problem list accuracy
Attend multidisciplinary patient rounds with care team
Communicate with care team regarding documentation opportunities and ICD 10 specificity
Verify the response from care team to clarification of diagnoses both inpatient and outpatient.
Identify and arrange education for new providers soon after onboarding
Develop educational offerings for new providers and ongoing education updates for clinical staff
Identify trends/opportunities for improvement in documentation habits of service line and report that information to the attending group in education session
Expert knowledge of EHR use and tools available for clarification presentation and tracking
Maintain expert knowledge of current changes of ICD 10 requirements and educate providers to needed changes in documentation
Maintain open communication with HIM coding staff, CDS, physician abstractors, coding integrity personnel and CDI physician liaison to accurately reflect the diagnoses in documentation
Actively seek new opportunities to review records and offer documentation education and advice
Active involvement in post coding review of charts for accurate reflection of diagnosis coding
Maintains a program of personal and professional growth and development.
Performs assigned work safely, adhering to established departmental safety rules and practices; reports to supervisor, in a timely manner, any unsafe activities, conditions, hazards, or safety violations that may cause injury to oneself, other employees, patients and visitors. Promotes safe work habits, rules, and practices among staff.
Facilitates a team process problem solving approach utilizing the Hospital/Health system resources across the care continuum.
Prepares for, attends and participates in all assigned committees and CDI presentations
Participates in and organizes ongoing educational services for staff and providers, including comprehensive orientation programs, cross training and proactive CDI processes.
Identifies trends and/or opportunities to improve clinical documentation. Presents opportunities and potential solutions to the clinical documentation team
All other duties as assigned.
Our dedication to professionals who are dedicated to children frequently earns Nemours a spot on the list of top workplaces in the communities we serve. Our Associates enjoy comprehensive benefits, including our unique “Bridge to a Healthy Future” pediatric health plan, an integrated wellness program, opportunities for professional growth, and much more. As an equal opportunity employer, Nemours focuses on the best-qualified applicants for our openings.
Nemours is a pediatric health system of hospitals and specialty clinics serving children and families throughout the Delaware Valley and Florida. Our dedicated professionals integrate medical care, research, health education, and prevention to help improve the lives of children every day.