Carolinas HealthCare System
Job Req ID: 157453
Position Number: 00149485
Employment Type: Part Time
Shift: Variable/On Call
Shift Details: *Flexible day shift, No weekends
Standard Hours:Â 20.00
Department Name: Clinical Case Management
Location: CHS Cleveland
Location Details:Â Ability to orient 12 weeks in Charlotte
Carolinas HealthCare System is Atrium Health. Our mission remains the same: to improve health, elevate hope and advance healing - for all. The name Atrium Health allows us to grow beyond our current walls and geographical borders to impact as many lives as possible and deliver solutions that help communities thrive. For more information, please visit carolinashealthcare.org/AtriumHealth
Â Job Summary
Responsible for concurrently reviewing inpatient medical records to identify vague, inconsistent or incomplete documentation within the medical record and assigns the most appropriate medical severity diagnostic related group (MS-DRG). Essential Functions
- Reviews selected populations of inpatient medical records to identify the principal and/or secondary diagnoses. Appropriately assigns the MS-DRG that most accurately reflects the severity of illness of the patient based upon the clinical evidence documented at the time of the record review.
- Demonstrates knowledge and understanding of severity based DRG systems; All Patient Refined and Medicare Severity (AP-DRG) and Medical Severity Diagnostic Related Group System (MS-DRG).
- Demonstrates the ability to utilize the licensed software tool to perform and record daily medical record reviews.
- Interacts with the physician and/or other designated members of the healthcare team to ensure that vague or incomplete documentation is clarified within the medical record in a timely manner.
- Works with other departments such as coding, corporate compliance, quality and finance to support Corporate Goals.
- Participates in the ongoing education of physicians, nurse practitioners, physician assistants and other healthcare team members in an effort to identify medical record documentation improvement opportunities employing conflict resolution skills as necessary.
- Utilizes critical thinking skills based upon extensive knowledge of disease processes and clinical outcomes to identify the need for further clarification of physician documentation within the medical record.
- Ensures that all written requests to physicians for additional documentation support Corporate Compliance policies.
Works in an office type setting, extensive walking throughout the facility. Prolonged periods of sitting reviewing medical records and documentation. Repetitive wrist motion and occasional lifting of 10-20 pounds. Intact sight and hearing with or without assistive devices is required.Education, Experience and Certifications
Registered Nurse North Carolina Licensure required. Bachelors Degree Preferred. Obtain and maintain CCDS or Coding Certification within 2 years of employment. Applicants who do not successfully pass exam during initial 2 year period must successfully pass the exam within the following year. 5 years of related nursing experience preferred. Clinical experience within the assigned population. Extensive knowledge of disease processes and clinical outcomes. Case Management experience or background helpful. Strong financial and analytical skills preferred. Word, Outlook, Excel experience preferred. Must speak English fluently and write English in understandable terms.
At Carolinas HealthCare System, our patients, communities and teammates are at the center of everything we do. Our commitment to diversity and inclusion allows us to deliver care that is superior in quality and compassion across our network of more than 900 care locations.
As a leading, innovative health system, we promote an environment where differences are valued and integrated into our workforce. Our culture of inclusion and cultural competence allows us to achieve our goals and deliver the best possible experience to patients and the communities we serve.
Posting Notes: Not Applicable
Carolinas HealthCare System is an EOE/AA Employer