Compliance Documentation Improvement Specialist Atrium Health Pineville Hybrid FT Days Position Available In Mecklenburg, North Carolina
Tallo's Job Summary: The Compliance Documentation Improvement Specialist at Atrium Health Pineville ensures accurate clinical documentation within the electronic medical record. They collaborate with providers to enhance quality and completeness of documentation, educate the care team on coding and compliance, and review medical records to assign appropriate diagnosis codes. This role requires a Registered Nurse license, a Bachelor's Degree, and relevant nursing experience. Atrium Health is hiring for this position, offering competitive benefits and a chance to be part of a leading healthcare organization.
Job Description
- Job Summary
- Assists treating providers to ensure documentation in the medical record accurately reflects the severity of illness of the patient as well as the level of service rendered.
Uses clinical/nursing knowledge and understanding of national coding guidelines and standards of compliance to improve overall quality and completeness of clinical documentation within the patient electronic medical record using a multidisciplinary team process. Works collaboratively with physicians and advanced practice providers to ensure the clinical information within the medical record is accurate, complete, and compliant. Educates members of the patient care team both formally and informally regarding documentation guidelines, coding requirements and service specific requirements.
- Essential Functions
- + Reviews selected populations of inpatient medical records to identify the principal and/or secondary diagnoses.
Appropriately assigns the MS-DRG that most accurately reflects the severity of illness of the patient based upon the clinical evidence documented at the time of the record review. + Demonstrates knowledge and understanding of severity based DRG systems; All Patient Refined and Medicare Severity (AP-DRG) and Medical Severity Diagnostic Related Group System (MS-DRG). + Demonstrates the ability to utilize the licensed software tool to perform and record daily medical record reviews. + Interacts with the physician and/or other designated members of the healthcare team to ensure that vague or incomplete documentation is clarified within the medical record in a timely manner. + Works with other departments such as coding, corporate compliance, quality, and finance to support Corporate Goals. + Participates in the ongoing education of physicians, nurse practitioners, physician assistants and other healthcare team members to identify medical record documentation improvement opportunities employing conflict resolution skills as necessary. + Utilizes critical thinking skills based upon extensive knowledge of disease processes and clinical outcomes to identify the need for further clarification of physician documentation within the medical record. + Ensures that all written requests to physicians for additional documentation support Corporate Compliance policies.
- Physical Requirements
- Works in an office type setting, extensive walking throughout the facility. Prolonged periods of sitting reviewing medical records and documentation. Repetitive wrist motion and occasional lifting of 10-20 pounds. Intact sight and hearing with or without assistive devices are required. Ability to speak English fluently and write in understandable terms.
- Education, Experience and Certifications
- Registered Nurse North Carolina Licensure required.
Bachelor’s Degree Required. Appropriate professional certification required within 3 years of hire date per department protocol. 5 years of related nursing experience preferred. Clinical experience within the assigned population. Extensive knowledge of disease processes and clinical outcomes. Case Management experience or background helpful. Strong financial and analytical skills preferred. Word, Outlook, Excel experience preferred. Atrium Health is one of the nation’s leading healthcare organizations, connecting patients with on-demand care, world-class specialists and the region’s largest primary care network. A recognized leader in healthcare delivery, quality and innovation, our foundation rests on providing clinically excellent and compassionate care. We’ve been serving our community since 1940, when we opened our doors as Charlotte Memorial Hospital. Since then, our network has grown to include more than 40 hospitals and 900 care locations ranging from doctors’ offices to behavioral health centers to nursing homes.
Our focus:
Delivering the highest quality patient care, supporting medical research and education, and joining with partners outside our walls to keep our community healthy.
