Clinical Documentation Specialist - Behavioral Health Nursing
ChristianaCare Health System
Location: Wilmington, Delaware
Internal Number: JR59991
Are you interested in driving healthcare forward? Some of the best hospital care available in the United States is right here in Delaware!
ChristianaCare, a healthcare organization with 1100 beds between two Magnet(r) recognized hospitals (Christiana and Wilmington) and the only Level 1 Trauma service on the East Coast corridor between Philadelphia and Baltimore. Honored repeatedly as "One of America's Best Hospitals" by U.S. News & World Report!
Christiana Care is currently seeking a Clinical Documentation Specialist - Behavioral Health Nursing
HIGHLIGHTS: We offer robust healthcare benefits, tuition reimbursement, competitive pay and a 403b plan.
Make a difference in the lives of our patients.
Forbes Magazine named us as a Top Best Employer.
PRIMARY FUNCTION: Responsible to ensure that health care services are administered with quality, cost efficiency, and within compliance, along with improving and ensuring the overall quality, cost efficiency and completeness of documentation within the inpatient medical record. Continuously reviewing and auditing patient medical records (Psych Crisis and inpatients), screening for unnecessary procedures, ineffective treatments, and unnecessarily extensive hospital stays. Educates members of the patient care team on documentation guidelines on an ongoing basis. Facilitates modifications to clinical documentation through extensive concurrent interaction with physicians, coding staff and other members of the healthcare team to support the appropriate reimbursement and clinical severity are captured compliantly for the level of service rendered to all patients.
RESPONSIBILITIES: - Concurrent review of inpatient medical records (Psych Crisis and inpatient) throughout the patient's hospitalization.
- Analyzes clinical status of patient, current treatment, past medical history and identifies potential gaps in physician documentation.
- Obtains continued insurance authorization for continued stay of patients
- Obtain initial insurance authorization for direct admissions and admissions from medical units as needed
- Obtains Electro Convulsive Therapy (ECT) insurance pre-auth as needed for inpatient
- Communicates with physicians or other providers to validate admission status and appropriately prompts for documentation if necessary, either verbally or written.
- Educates physicians and other key healthcare providers regarding clinical documentation improvement and the need for accurate and complete documentation in the health record.
- Reviews and clarifies clinical issues in the health record with the coding professionals that would support an accurate DRG assignment, severity of illness, and/or risk of mortality.
- Monitors patients progress; consults with primary physician or designee and other members of the care delivery team at agreed-upon intervals, or more frequently, as needed.
- Participates in performance improvement activities.
- Maintains confidentiality of patients/members and staff information.
- Attends coding/financial/utilization management educational programs and regulatory educational programs and updates as necessary to maintain proficient knowledge base.
- Performs assigned work safely, adhering to established departmental safety rules and practices; reports to supervisor, in a timely manner, any unsafe activities, conditions, hazards, or safety violations that may cause injury to oneself, other employees, patients and visitors.
- Performs other related duties as required.
REQUIREMENTS: - Bachelor's Degree in Nursing
- Registered RN licensed to practice in the State of DE required
- Minimum of 3 years recent experience as a Registered Nurse. Acute care psych preferred.
- Clinical Documentation, Performance Improvement, Case Management or Utilization Management experience desirable.
- Clinical Documentation Certification (CCDS) required within 1 year of eligibility.
Hours: The hours for this position are typically Monday - Friday 8 a.m. - 4:30 p.m. No weekends or holidays.
EEO Statement: Christiana Care Health System is an equal opportunity employer, firmly committed to prohibiting discrimination, whose staff is reflective of its community, and considers qualified applicants for open positions without regard to race, color, sex, religion, national origin, sexual orientation, genetic information, gender identity or expression, age, veteran status, disability, pregnancy, citizenship status, or any other characteristic protected under applicable federal, state, or local law.
UPDATE: ChristianaCare is committed to prioritizing the health and safety of our patients and caregivers. As we continue to meet the needs of our caregivers and our community through the COVID-19 pandemic, our commitment to health and safety requires that we take new steps to ensure a safe environment for medical care for our patients and a workplace that avoids preventable harm for our caregivers. For this reason, vaccination for COVID-19 is required for all caregivers at ChristianaCare and is considered a safety standard that is job-related and consistent with business necessity for all caregivers.
ChristianaCare Health System is headquartered in Wilmington, Delaware and is one of the country's largest health care providers, ranking 21st in the nation for hospital admissions. Christiana Care is proudly a Nurse Magnet recognized institution. Christiana Care Health System is also one of the largest health care providers in the mid-Atlantic region, serving all of Delaware and portions of seven counties bordering the state in Pennsylvania, Maryland and New Jersey. A not-for-profit, non-sectarian health system, Christiana Care includes two hospitals with more than 1,100 patient beds, and is a major teaching hospital with two campuses. Christiana Care is continually recognized for excellence on a regional and national level. Our role in the community is expressed in the Christiana Care Way: "We serve our neighbors as respectful, expert, caring partners in their health. We do this by creating innovative, effective, affordable systems of care that our neighbors value."Christiana Care is a great place to work because we value diversity and recognize it to be a core part of our success. Because of the diversity of our employees, affiliated health professionals and volunteers, we are ...positioned to meet the unique needs of our patients and community. We acknowledge and celebrate the uniqueness and talent of each employee. Because of our talented workforce we are able to provide a quality healthcare experience to our patients and community. We strive to create an inclusive environment in which individual diversity can be leveraged and thrive. Christiana Care Health System is an equal opportunity employer, firmly committed to prohibiting discrimination, whose staff is reflective of its community and considers qualified applicants for open positions without regard to race, color, sex, religion, national origin, sexual orientation, genetic information, gender identity or expression, age, veteran status, disability, pregnancy, citizenship status, or any other characteristic protected under applicable federal, state, or local law.