Job Description:
• Review inpatient medical records to ensure accurate, complete, and compliant clinical documentation
• Perform concurrent and/or retrospective reviews of inpatient medical records for documentation accuracy, completeness, and compliance
• Maintain an accuracy rate of 98%
• Identify opportunities for clarification of diagnoses, procedures, present on admission (POA) indicators, severity of illness, risk adjustment, and clinical validation
• Initiate compliant physician queries to clarify conflicting, incomplete, or nonspecific documentation
• Collaborate with coding staff to ensure accurate ICD-10-CM/PCS coding and MS-DRG/APR-DRG assignment
• Monitor documentation trends related to mortality, quality indicators, hospital-acquired conditions (HACs), patient safety indicators (PSIs)
• Conduct clinical validation reviews for high-risk conditions
Requirements:
• Valid Registered Nurse license with a bachelor’s degree or higher (completed and verified prior to start)
• Seven (7) years of Nursing experience
• Five (5) years of experience in the inpatient acute care setting
• Experience auditing practices, ICD 10, PCS guidelines, quality initiatives, and MS-DRG and APR DRG methodologies
• Clinical knowledge and application to coding
• Experience in CCDS, CCS, or CDIP with (7) seven years of clinical documentation/DRG validator
• Knowledge of the Solventum HIS software portfolio (e.g., 360 Encompass)
Benefits:
• Medical, Dental & Vision
• Health Savings Accounts
• Health Care & Dependent Care Flexible Spending Accounts
• Disability Benefits
• Life Insurance
• Voluntary Benefits
• Paid Absences
• Retirement Benefits