ICU Clinical Documentation Registered Nurse RN- Hybrid

Job description

Hybrid role: MUST live within 1hr of Alabaster, AL. JOB SUMMARY: Responsible for reviewing medical records to facilitate and obtain appropriate physician documentation for any clinical conditions or procedures to support the appropriate severity of illness, expected risk of mortality, and complexity of care of the patient, by improving the quality of the physicians’ clinical documentation. Exhibits a sufficient knowledge of clinical documentation requirements, MS-DRG Assignment, and clinical conditions or procedures. Educates members of the patient care team regarding documentation guidelines, including attending physicians, allied health practitioners, nursing, and case management. ESSENTIAL DUTIES AND RESPONSIBILITIES: Include the following. Others may be assigned. - Record Review: Completes initial medical records reviews of patient records within 24-48 hours of admission for a specified patient population to: (a) evaluate documentation to assign the principal diagnosis, pertinent secondary diagnoses, and procedures for accurate MS-DRG assignment, risk of mortality and severity of illness; and (b) initiate a review worksheet. - Conducts follow-up reviews of patients every 2-3 da...