Documentation Review Nurse

Hunterdon Healthcare System, 2100 Wescott Drive, Flemington, NJ

Full-time

n/a, All Shifts

Req # 77557

Position Summary

The Clinical Documentation Review Nurse will apply expertise and knowledge and review clinical documentation of Emergency Department (ED) Records to ensure accuracy, completeness, and compliance with coding and billing standards for reimbursement purposes. This position will be reviewing the coding and documentation of nurses, physicians and advanced practice providers. The position will support data integrity and will collaborate closely with physicians, coders, and other healthcare professionals to optimize documentation practices, improve the accuracy of coding and maximize reimbursements and minimize billing denials.

Primary Position Responsibilities

• Clinical Documentation Review: Assess emergency department documentation using Emergency Department E/M and Critical Care Facility Charge Assessment tool to ensure the patient documentation accurately reflects the patient’s clinical presentation, diagnoses, and captures all treatment and services provided.
• Coding Compliance: Verify that documentation support the appropriate ICD-10, CPT, and HCPCS codes for billing and reimbursement.
• Education and Feedback: Provide constructive feedback and education to ED team on documentation practices to improve compliance and clarity.
• Audit Preparation: Assist in preparing documentation for internal and external audits to ensure readiness and compliance.
• Collaboration with Coders: Work closely with coding professionals to address discrepancies and clarify documentation for accurate coding.
• Regulatory Compliance: Ensure all documentation aligns with regulatory requirements, payor policies, and industry standards.
• Performance Metrics: Track and report on documentation trends, identifying areas for improvement to enhance reimbursement and reduce denials.
• Continuous Learning: Stay up to date on changes in coding guidelines, payor requirements, and clinical documentation standards.
• HIPAA Compliance: Maintain strict HIPAA compliance and confidentiality in reference to all information reviewed and/or discussed.
• Utilize effective critical thinking skills to resolve issues and assess and implement improved methods for efficient capture of patient services in compliance with coding and documentation regulations to ensure revenue capture and reduce denials and appeals.
• Work closely with 3rd party vendors, IT, and internal revenue cycle teams to resolve data quality issues
• Other duties as assigned: to support the unit, department, entity and health system.

Qualifications

• Minimum Education:
• Required: Registered Nurse (RN) with an active and unencumbered license
• Preferred: Bachelor of Science in Nursing (BSN) preferred
• Minimum Years of Experience (Amount, Type and Variation):

(Amount, Type and Variation)

• Required: minimum of three (3) years clinical nursing experience
• Preferred: previous nursing experience in an emergency department
• License, Registry or Certification:

• 1. Knowledge of Medicare reimbursement and coding structures/systems
• 2. Experience in clinical documentation improvement (CDI), coding or utilization review is highly desirable/preferred
• 3. Certification in Clinical Documentation Improvement (example – CCDS, CDIP) or coding (example CPC, CCS) preferred or willingness to obtain within one year of hire.

• 1. Strong understanding of ICD-10, CPT and HCPCS coding principles
• 2. Excellent analytical, organizational and communication skills
• 3. Proficient in electronic health records (EHRs) and clinical documentation systems
• 4. High level creativity, judgment and initiative, tempered with flexibility to deal with rapidly changing healthcare environment and expanding technology
• 5. Ability to maintain concentration with attention to detail even in areas containing multiple levels of distraction
• 6. Self-motivated, well organized and possess confidence and ability to wor work independently and deal with ambiguity and ask critical questions to problem solve issues as required.
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