RN MDS McAuley Center FTRequisition R003251 Market Urbana, OH Department Nursing Administration - Mercy McAuley Center Shift Days Schedule Full-time
Thank you for considering a career at Mercy Health
This job description is not intended to be and should not be construed to be an exhaustive list of all the duties and responsibilities performed. This is not a comprehensive listing of all responsibilities and duties that may be assigned by the supervisor. The job description is subject to continual revisions as needed for resident care. Due to the services and care provided by this institution, personnel may be requested to serve in related capacities as determined by their qualifications in a different unit, department, and campus, in an effort to not disrupt resident care and continue to provide a safe environment to our residents.
A summary of the specific skills, knowledge and behaviors of this position are: Facilitates improvement in the overall quality, completeness and accuracy of medical record documentation. Obtains and promotes appropriate clinical documentation through extensive interaction with physicians, nursing staff, other patient caregivers and Health Information Management coding staff to ensure clinical documentation reflects the level of service rendered to patients is complete and accurate. Educates all members of patient care team on documentation guidelines, on an on-going basis.
This position requires the incumbent to demonstrate proficiency in clinical skills for residents in the following age categories:
Incorporates the Core Values and Success Factors that support the Mission and Vision of Catholic Health Partners.
Facilitates appropriate clinical documentation to ensure the level of services and acuity of care are accurately reflected in the medical record. Performs admission reviews for specific patient populations using clinical documentation guidelines. Assists in medical screening process by documenting appropriateness of patient admission, working DRG & LOS info on worksheet and computer system as appropriate. Extensively reviews all physician and clinical documentation, lab results, diagnostic information, and treatment plans and captures appropriate information on CDMP® worksheet. Utilizes clinical skills to identify documentation opportunities that reflect severity of illness, acuity and resource consumption. Verbally communicates with appropriate physician(s) to ensure documentation opportunities are clarified. Communicates with ancillary personnel (e.g., PT, ET) to clarify potential documentation opportunities.
Updates DRG worksheet to reflect any changes in patient status, procedures/treatments, and confers with physician to finalize diagnoses. Reviews medical record every 24-48 hours as appropriate. Updates Clinical Documentation Management Program worksheet to reflect additional physician documentation, lab findings, diagnostic test results and treatment as appropriate. Updates Clinical Documentation Management Program worksheet to reflect any changes in DRG assignment. Communicates with physician to ensure that request for documentation has been noted. Confers with physician to establish appropriate severity of illness and ensure documentation of principal diagnosis, comorbid conditions, complications and procedures.
Conducts follow-up reviews of clinical documentation to ensure issues discussed and clarified with the physician have been documented in patient’s chart. As appropriate, documents, analyzes data and reports instances of inappropriate patient care, discharge delays, etc. to Manager of Health Records Services. Follows established CDMP® process for follow-up reviews and physician communication.
Reviews clinical issues with coding staff to assign working DRG using software. Collaborates with coding staff as needed to determine appropriate DRG and required documentation. Utilizes coding staff knowledge of Coding Clinics that impact CDMP®. Provides clinical expertise and references to the coding staff. Follows established guidelines for reconciling final coded DRG with the CDMP® DRG assigned at the time of discharge.
Stays current with and conducts on-going clinical documentation management program education for new staff, including new clinical documentation specialists, physicians and nursing and allied health professionals. Tracks and trends program compliance. Attends and participates in weekly educational conferences. Participates in concurrent performance improvement activities and on-going MR review activities. Reviews CDMP® tracking data in conjunction with established benchmarks. Provides overview of CDMP® to new staff, allied health professionals and physicians.
Maintains positive and open communications with physicians, interdisciplinary care team members, coding staff, Regional Manager of Coding, Quality and Compliance.
This position WILL be included in the on call RN rotation for McAuley Center
Associates of Nursing degree required
40 hrs a week
M-F (with the addition of participating in the ON CALL rotation)
Mercy Health is an equal opportunity employer.
We’ll also reward your hard work with:
- Comprehensive, affordable medical, dental and vision plans
- Prescription drug coverage
- Flexible spending accounts
- Life insurance w/AD&D
- An employer-matched 403(b) for those who qualify.
- Paid time off
- Educational Assistance
- And much more
Scheduled Weekly Hours:40
Department:Nursing Administration - Mercy McAuley Center
All applicants will receive consideration for employment without regard to race, color, national origin, religion, sex, sexual orientation, gender identity, age, genetic information, or protected veteran status, and will not be discriminated against on the basis of disability. If you’d like to view a copy of the affirmative action plan or policy statement for Mercy Health – Youngstown, Ohio or Bon Secours – Ashland, Kentucky, which is an Affirmative Action and Equal Opportunity Employer, please email firstname.lastname@example.org. If you are an individual with a disability and would like to request a reasonable accommodation as part of the employment selection process, please contact The Talent Acquisition Team at email@example.com
I wanted to get into a career where I’m happy to go to work.Luis F. RN