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Hours Full-time, Part-time
Location Bakersfield, CA
Bakersfield, California

About this job

For those who want to invent the future of health care, here's your opportunity. We're going beyond basic care to health programs integrated across the entire continuum of care. Join us and help people live healthier lives while doing your life's best work.(sm)

 
The Clinical RN Document Improvement Specialist - (CDS) is responsible for providing CDI program oversight and day to day CDI implementation of processes related to the concurrent review of the clinical documentation in the inpatient medical record of Optum 360 clients' patients.  The goal of the CDS oversight and practice is to assess the technical accuracy, specificity, and completeness of provider clinical documentation, and to ensure that the documentation explicitly identifies all clinical findings and conditions present at the time of service. 



This position collaborates with providers and other healthcare team members to make improvements that result in accurate, comprehensive documentation that reflects completely, the clinical treatment, decisions, and diagnoses for the patient.  Utilizing  clinical expertise and clinical documentation improvement practices and facility specific tools for best practice and compliance with the mission/philosophy, standards, goals and core values of Optum 360.  This position does not have patient care duties, does not have direct patient interactions, and has no role relative to patient care.


 


***This will be a office position located in the Bakersfield Memorial Hospital in Bakersfield, CA***


 


***Must be able to work weekends; Schedule of Sunday thru Thursday with Friday & Saturday off; or Tuesday-Saturday with Sunday and Monday off***



Responsibilities:




  • Provides expert level review of inpatient clinical records within 24-48 hours of admit; identifies gaps in clinical documentation that need clarification for accurate code assignment to ensure the documentation accurately reflects the severity of the patient condition and acuity of care provided. 


  • Conducts daily follow-up communication with providers regarding existing clarifications to obtain needed documentation specificity.


  • Provides expert level leadership for overall improvement in clinical documentation by providing proficient level review and assessment, and effectively articulating recommendations for improvement, and the rational for the recommendations. 


  • Actively communicates with providers at all levels, to clarify information and to communicate documentation requirements for appropriate diagnoses based on severity of illness and risk of mortality.


  • Provides complete follow through on all requests for clarification or recommendations for improvement.


  • Leads the development and execution of physician education strategies resulting in improved clinical documentation.


  • Provides timely feedback to providers regarding clinical documentation opportunities for improvement and successes.


  • Ensures effective utilization of the Midas Clinical Documentation Improvement Focus Study, documenting all verbal, written, electronic clarification activity.


  • Utilizes only the facility/Optum 360 approved forms, whether paper or electronic.


  • Steers the development and implementation of education plans for the interdisciplinary care team to promote accurate and complete documentation in the medical record.


  • Proactively develops a reciprocal relationship with the HIM Coding Professionals.


  • Coordinate and conducts regular meeting with HIM Coding Professionals to monitor retrospective query rate and address issues.


  • Engages and consults with Physician Advisor when needed to resolve provider issues regarding answering clarifications and participation in the clinical documentation improvement process.


  • Actively engages Case Management and RAC committee to continually evaluate and spearhead clinical documentation improvement opportunities to reduce denials and support medical necessity.

Requirements



  • BSN required or matriculating in a national or state approved BSN program


  • Current Registered Nurse (RN) License  within the state in which you reside


  • Must be comfortable communicating & working closely with Physicians


  • Minimum of five  years acute care hospital clinical RN experience required


  • Previous experience in case management and/or critical care preferred


  • Excellent verbal and written skills including strong organizational skills


  • Relevant Certification required (CCDS) is preferred


  • Familiarity with ANA "Nursing: Scope of Standards of Practice"; ANA "Code of Ethics for Nurses with Interpretive Statements"; Nurse Practice Act for State of Employment Core Measure; AHIMA Practice Brief "Achieving a Compliant Query Practice"


  • Basic understanding of Microsoft, Word, Excel, and work related software.

 


Health care isn't just changing. It's growing more complex every day. ICD10 replaces ICD9. Affordable Care adds new challenges and financial constraints. Where does it all lead? Hospitals and health care organizations continue to adapt, and we are a vital part of their evolution. And that's what fueled these exciting new opportunities.



Optum360 is a dynamic new partnership formed by Dignity Health and Optum to combine our unique expertise. As part of the growing family of UnitedHealth Group, we'll leverage all our resources to bring financial clarity and a full suite of revenue management services to health care providers nationwide.


 


Diversity creates a healthier atmosphere: All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, protected veteran status, or disability status.


 


UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment. In addition, employees in certain positions are subject to random drug testing.


 


Key Words: ICD 9, coding, RN, Registered Nurse, Nurse, case management, critical care, BSN, clinical documentation, Bakersfield, CA, Bakersfield Memorial Hospital