Registered Nurse Clinical Document Integrity (Memphis, TN)

Job Description

Job Description

Company Description

International SOS Government Medical Services, Inc. delivers customized medical and security risk management and wellbeing solutions to enable our clients to operate safely and effectively in environments far from home. Founded in 1984, we operate in 92 countries providing integrated medical solutions to organizations with international operations. Our innovative technology and medical and security expertise focus on prevention, offering real-time, actionable insights and on-the-ground quality delivery. We provide clinical services to include “hands on” direct care at over 800 sites around the world, many of which include inpatient clinical care capabilities. With 12,000 staff (including 5,200 medical and behavioral health providers) our services include the design, deployment, and operation of healthcare solutions including freestanding surgical facilities in remote and austere environments, telemedicine consultation through a wide range of virtual modalities, referrals to a global network of more than 100,000 vetted providers, and global aeromedical evacuation. Within our portfolio of companies, International SOS Government Medical Services, Inc., headquartered in Houston, Texas provides contracted healthcare support to Government defense and civil agencies and government contractors, including support to military exercises and operations, diplomatic missions, natural disasters, and refugee care. To protect your workforce, we are at your fingertips : internationalsos.com

Job Description

This position is contingent on contract award.

This position will support the US Department of Veterans Affairs Critical Staffing Program.  The person in this position will represent International SOS Government Medical Services, Inc. and provide services outlined below :

International SOS Government Medical Services, Inc. is looking for an individual who is an experienced Registered Nurse Clinical Documentation Integrity Specialist (CDIS) to ensure the accuracy, completeness, and compliance of clinical documentation within healthcare records, facilitating optimal patient care and appropriate reimbursement. The Nurse collaborates with healthcare providers to improve documentation practices, thereby enhancing the quality of patient data and promoting better health outcomes.

Key Responsibilities :

• Accountable for using a variety of collaborative strategies with Physicians, Clinical Documentation multi-disciplinary team members, Facility Revenue Management team, and Health Information Management (HIM) staff.
• Ensure clinical documentation and services rendered to patients is complete and accurate.
• Ensure the accuracy and completeness of clinical information used for measuring and reporting physician and medical center outcomes with continuing education to all members of the patient care team on an ongoing basis.
• Collaboratively work with the professional clinical staff and provides support and education on documentation issues.
• Maximize third party collections and document the delivery of quality patient care services.
• Perform complete and timely documentation related to the necessary onsite inpatient and outpatient services.
• Collaborate with health care providers and licensed independent providers through written, verbal, or electronic clarification requests or queries.
• Reference or cite facility’s SOP, CDI Program Guides serving as primary tools used by CDI to improve clinical documentation in the health record.
• Use knowledge and critical thinking skills when reviewing episodes of care.
• Provide education to licensed independent providers, allied health professionals, and coding staff on clinical documentation integrity issues.
• Develop the facility’s CDI management program that encompasses inpatient and outpatient billable and non-billable services.
• Develop and implement active training and education programs (i.e., seminars, workshops, short courses, informational briefings, and conferences).
• Provide training in small or large groups, educating clinical staff about current documentation standards and improving techniques, including accurate and ethical documentation practices.
• Develop and implement Standard Operating Procedures workflow, templates consistent with the most current standards of The JC unless otherwise stated.
• Develop an improvement plan to focus on updating problem lists or Scientific Nomenclature of Medicine – Clinical Terminologies (SNOMED-CT) consistent with ICD 10 CM code sets predominantly outpatient abstracts.
• Assist clinical providers to document the specific interventions, such as medications, diagnostic tests, therapies, or other treatments.
• Discern during their concurrent review for admission order language used to specify inpatient or outpatient status is ambiguous, the best course of action would be to obtain and document clarification from the ordering practitioner before initial billing prior to discharged.
• Prevent denials to continue to treat orders that specify a typically outpatient or other limited service (e.g., admit to emergency room to Observation, to Recovery to Outpatient surgery to Day surgery, or to short stay surgery as defining a non-inpatient service.
• Accountable for maintaining thorough and working knowledge of the VHA Resident Supervision Documentation Guidelines, the Joint Commission, Centers for Medicare and Medicaid Services (CMS), and VHA guidelines on medical record rules of documentation.
• Assist with CDI specific topics in the Medical Center newsletter or other communication vehicles to further educate the clinical staff.
• Assist and develop presentation materials for provider education on documentation and its impact.
• Assist with education of CDIS and Coding staff on the identification of clinical indicators for disease processes.
• Conduct concurrent or retrospective review of the health record when requested by HIM or the CDIS to clarify clinical questions and potential query opportunities identified by HIM or CDIS during their record reviews.
• Review documentation issues identified during chart reviews by the CDIS and Coding, including, but not limited to common issues such as congestive heart failure, chronic kidney disease, urosepsis, pneumonia, anemia, and respiratory failure which may represent improved documentation through provider education.
• Assist health record review process, quality assurance, mortality reviews, CMS core measures, and other quality initiatives as indicated by facility needs.
• Be familiar with VHA Reconciliation which is also a critical CDI activity.
• Completes required organizational compliance education, including assigned requirements that are client-specified, for Joint Commission Healthcare Staffing Services certification or other regulatory bodies.

This list is non-exhaustive, and the role holder may be required to undertake additional duties that are not specifically listed above.

Qualifications

Basic Requirements / Certifications :

Education Required :

Bachelor of Science in Nursing (BSN).

Physical Requirements :

Other Special Qualifications :

Additional information required for final submission :

Additional Information

Pay range is based on several factors and may vary in addition to a full range of medical, financial, and / or other benefits. Final salary and offer will be determined by the applicant’s background, experience, skills, internal equity, and alignment with geographical market data.

Benefits – Full-time positions are eligible for our comprehensive and competitive benefits package including medical, dental, vision, and basic life insurance. Additional benefits include a 401k plan paid time off and an annual bonus. International SOS Government Medical Services, Inc. complies with all federal, state, and local minimum wage laws.

International SOS Government Medical Services, Inc. is an equal opportunity employer and does not discriminate against employees or job applicants on the basis of race, color, religion, gender, sexual orientation, gender identity, national origin, age, disability, genetic information, marital status, amnesty or status as a covered veteran in accordance with the applicable federal, state and local laws.