Reporting to the Manager, HIM, Health Information Mgmt, this position is responsible for improving medical record physician documentation by performing concurrent medical record reviews and addressing incomplete documentation with physicians. Indirectly assures case mix index, DRG assignment and severity/mortality profiles are accurate. Performs concurrent program activities to accomplish and enhance the above.
1. Current licensure as a Registered Nurse is required. California RN licensure is preferred.
2. Approximately five years of acute care nursing is required.
3. Knowledge of data retrieval from medical records; QIO; perspective payment system (PPS); medical terminology; anatomy, physiology and disease pathology; and regulatory requirements set forth by QIO and CMS is required.
4. Knowledge of report-writing; basic computer and data entry; mathematical calculations; Utilization Review/Management; and clinical skills is required.
5. Ability to communicate effectively, both orally and in writing, accuracy, resourcefulness, interpersonal skills, critical thinking and decision-making skills, adaptability and supportive to change, detail-oriented and professionalism are required.