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Clinical Documentation Registered Nurse II - Document Integrity

Company

Christus Health

Location

Beaumont, Texas

Type

Full-time

Summary:


This position is responsible for facilitating improvement in the overall quality and completeness of the medical record documentation. The clinical documentation RN will provide support and expertise through comprehensive assessment and review of inpatient medical records. The clinical documentation RN will facilitate accurate DRG assignment and obtain appropriate documentation through extensive interaction with physicians, patient caregivers and health information management coding staff to ensure that reimbursement is received for the level of services rendered to the patients.

Responsibilities:

  • Analyzes clinical status of patient, current treatment plan and past medical history and identifies potential gaps in physician documentation
  • Communicates with attending physician either verbally or through written methodology to validate observations and suggest additional and/or more specific documentation
  • Maintains positive open communic...
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