Jan 30, 2023

CLINICAL DOCUMENTATION IMPROVEMENT

  • Salina Regional Health Center
  • Salina, KS, USA

Job Description

  • POSITION SUMMARY
    • Position Summary:
      • Provides concurrent review of the clinical documentation in the medical record. Queries the medical staff and other caregivers as necessary via written/verbal communication to obtain accurate and complete physician documentation that supports the patient's severity of illness and risk of mortality. Performs a thorough chart review to identify comorbidities/complications, and documents these appropriately on the appropriate worksheet. Indirectly assures case mix index, DRG assignment and severity/mortality profiles are accurate. Concurrently reviews all inpatient/observation admissions for appropriate admission level order; works with caregivers as needed to complete admission orders. Demonstrates creativity and enthusiasm while pursuing the goals of the department and the organization. Maintains the ability to be flexible, and prioritizes daily responsibilities.
  • POSITION QUALIFICATIONS
    • Minimum Education
      • Associate or Diploma degree from an accredited registered nurse program
      • Bachelor's Degree in nursing preferred
    • Minimum Experience
      • 3 years recent clinical nursing experience
    • Required Registration/License/Certification
      • Current Kansas RN license