Eisenhower Medical Center Rancho Mirage , CA 92270
Posted 2 weeks ago
Share Job:
chevron_left Back To Results
Located in the heart of the Coachella Valley, you have access to resort-style living and world-class amenities throughout Southern California.
Job Objective: A brief overview of the position.
Facilitates clinical documentation improvement through extensive daily interaction with physicians, caregivers, case management and coding staff to achieve timely, accurate, and complete documentation. In doing so, provides on-going physician/provider education and consultation to improve the accuracy, completeness, specificity and compliance of the in-patient acute care Medical Record. Educates physicians/providers, RNs and other healthcare disciplines in understanding the importance of accurate documentation that reflects EMC's patient population as it is related to severity of illness and risk of mortality.
Reports to
DIRECTOR, CASE MANAGEMENT
Supervises
None
Ages of Patients
Pediatric
Adolescent
Adult
Geriatric
Blood Borne Pathogens
Minimal/ No Potential
Qualifications
Education
Required: BSN or MSN or enrollment in an RN-BSN or RN-MSN program within 1 year of hire and completion within 5 years of hire if hired after July 1, 2012
Licensure/Certification
Required: Active California RN license
Preferred: CCS, RHIT, ICD-10 AHIMA training certification or equivalent
Experience
Required: A minimum of 5 years recent clinical nursing experience in an acute care setting.
Preferred: Knowledge of MS-DRG methodology and inpatient coding rules and regulations
Essential Responsibilities
Demonstrates compliance with Code of Conduct and compliance policies, and takes action to resolve compliance questions or concerns and report suspected violations.
Performs concurrent review of medical records and identifies areas of documentation requiring clarification of comorbidities, presence of complications and the presence of an opportunity to improve documentation from the physician to accurately assign the best DRG.
Reviews 25-35 records in assigned areas within 24 hours or first working day after admission and with evidence of ongoing record review at least every 48 hours when necessary.
Compiles data in Midas and maintains monthly and Quarterly records of outcomes that reflect improvement in Clinical Documentation Improvement financial performance. Tracks and reports financial and statistical data in designated system. Prepares monthly and quarterly reports for Director of Case Management
Communicates with and works collaboratively with coding personnel to determine outcomes regarding severity/complexity and to assure all opportunities have been pursued before patients' discharge from acute care setting.
Educates physicians and staff on Query tool as it relates to quality of documentation in the medical record.
Reviews all defined medical records to identify laboratory, radiology, cardiac & pulmonary information and procedures pertinent to the patient's care that is not clearly documented in the medical record.
Analyzes deficiencies and educates physicians in need for appropriate documentation to capture the complexity of care and the severity of illness.
Implements tracking systems to measure the effectiveness of education.
Develops and tracks, in cooperation with the coding department, outcomes related to education and follow-through by physicians regarding accurate complication/comorbidity documentation.
Interfaces with physician champion regarding educational opportunities for specific documentation with physicians identified as needed additional education.
Develops and updates pertinent policies and procedures and processes in collaboration with the Director of Case Management.
Obtains daily census and tracks defined admissions and discharges.
Maintains compliance to HIPAA and all other regulations related to patient confidentiality.
Educate nursing, ancillary, case management staff, and appropriate committees regarding the Clinical Documentation Improvement process and outcomes.
Communicate with team members and participate in appropriate committees to report outcome information.
Collaborate with the Utilization Management Specialist when continued stay or level of care issues are identified.
Assist the HIM department in facilitation of the physician query process after patient discharge.
Performs special projects and other duties as directed.
Apply Now
Share Job:
Eisenhower Health offers a generous benefits package and a matched retirement plan.
Employees are eligible to participate in a benefits program designed to make a difference for you and your family.
View Full Benefits
Connect with Our Recruitment Team
Meet Kate RN, BSN & Erika RN, BSN, our Nurse Recruiters at the following events and learn about Sign-on Bonuses, Relocation Assistance, and an amazing benefits package at Eisenhower Health.
American Association of Critical Care Nurses (AACN) NTI 2024
Denver, CO - 05/23 - 05/24
Booth #2082
Go to the event site
Association of Women's Health, Obstetric & Neonatal Nurses (AWHONN)
Phoenix, AZ - 06/7 - 06/11
Booth #1208
Go to the event site
American Association of Nurse Practitioners (AANP)
Nashville, TN - 06/25 - 06/30
Go to the event site
ANCC Magnet
New Orleans, LA - 10/30 - 10/2
Go to the event site
A Culture of Positivity and Support
From the beginning, this organization formed a culture based on strong values, commitments and a passion for service and professional excellence.
What Our Nurses Say
One of my very favorite things about working at Eisenhower Health is the culture on inclusivity that we have and a strong base for evidence-based practice.
Lori
Neonatal Nurse
One of the greatest things about working as a nurse at Eisenhower Health is how much support you get from Administration. We keep on improving the process here. It's a fantastic place to work.
Richard
Nursing Supervisor
My favorite thing about working at Eisenhower Health is the camaraderie within my unit and with the different departments.
Jennifer
Registered Nurse
Be a Part of an Award-Winning Team
Eisenhower Medical Center