·    Facilitates appropriateness of clinical documentation to ensure that documentation reflects the level of service rendered to all patients with a DRG based payor.

·    Demonstrates knowledge of DRG payor issues, optimization strategies, clinical documentation requirements and referral policies and procedures.

·    Improves the overall quality and completeness of clinical documentation by performing admission/continued stay reviews using clinical documentation Integrity (CDI) guidelines.

·    Ensures the accuracy and completeness of clinical information used for measuring and reporting physician and Huntsville Hospital outcomes.

·    Assisting in screening process, making referrals, interacting with case managers and clinical nurse specialists to ensure continuity of patient care.

·    Process discharges by updating the DRG worksheet to reflect any changes in status, procedures/treatments and conferring with physician to finalize diagnosis.

·    Educates all internal customers on clinical documentation opportunities, coding and reimbursement issues, as well as performance improvement methodologies.

·    Conducts follow-up reviews of clinical documentation to ensure points of clarification have been entered into the patient’s medical record.

·    Reviews clinical issues with coding staff to assign a working DRG.

·    Tracks response to CDI and trends completion of DRG worksheets.

·    Serves as a member of the CDI Work Group, assists with special projects as needed and performs related duties as assigned.

·    Maintains positive open communication with physicians, interdisciplinary team members, and the department’s director.

·    As appropriate, participates in QI/PI data collection, evaluation and recommendations for improvement.

·    Refers quality issues to the department’s director.

·    Demonstrates knowledge of the principles of growth and development over the life span of the patient to include pediatrics, adolescents, adults, and geriatrics

·    Graduate of an Accredited School of Nursing required.

·    Current Alabama Nursing License.

·    Prefer at least 5 to 7 years of critical care experience in an acute care hospital setting.