Job Summary: Responsible for concurrent auditing of medical record documentation to evaluate the documentation and utilization review of services to adequately reflect care provided and resources used. Responsibilities include facilitation of appropriate provider documentation of care to accurately reflect patient severity of illness and risk of mortality. Proactively solicits clarification from advanced practice providers and clinical staff in areas where further specificity is needed in the documentation and consults with appropriate provider when conflicting information appears in the medical record. Maintains documentation regarding results of audit activity and shares those with staff and management as necessary. Collects and analyzes data pertinent to documentation findings and outcomes for process improvement. This position supports the concepts and philosophies of nursing as well as sound business practices. Promotes and facilitates education to providers regarding disease processes. Communicates with appropriate heathcare team members to promote accurate and complete documentation of each patient encounter. Provides patient and family centered care. Age appropriate care is provided to patients and families. Supports and implements patient safety and other safety practices as appropriate. Maintains professional competencies by attending educational programs, participates in professional organizations, subscribing to the reading professional journals or other appropriate activities.
Education: Bachelors Degree in Nursing required. Current licensure as a registered nurse in the State of Minnesota required.
Experience: Minimum of 3 years nursing experience required.