Atrium Health Charlotte is seeking a Registered Nurse (RN) Med Surg for a nursing job in Charlotte, North Carolina.

• Specialty: Med Surg
• Discipline: RN
• Start Date: ASAP
• Duration: Ongoing
• Employment Type: Staff

Overview

Job Summary

Assists treating providers to ensure documentation in the medical record accurately reflects the severity of illness of the patient as well as the level of service rendered. Uses clinical/nursing knowledge and understanding of national coding guidelines and standards of compliance to improve overall quality and completeness of clinical documentation within the patient electronic medical record using a multidisciplinary team process. Works collaboratively with physicians and advanced practice providers to ensure the clinical information within the medical record is accurate, complete, and compliant. Educates members of the patient care team both formally and informally regarding documentation guidelines, coding requirements and service specific requirements.

Essential Functions

• Reviews selected populations of inpatient medical records to identify the principal and/or secondary diagnoses. Appropriately assigns the MS-DRG that most accurately reflects the severity of illness of the patient based upon the clinical evidence documented at the time of the record review.
• Demonstrates knowledge and understanding of severity based DRG systems; All Patient Refined and Medicare Severity (AP-DRG) and Medical Severity Diagnostic Related Group System (MS-DRG).
• Demonstrates the ability to utilize the licensed software tool to perform and record daily medical record reviews.
• Interacts with the physician and/or other designated members of the healthcare team to ensure that vague or incomplete documentation is clarified within the medical record in a timely manner.
• Works with other departments such as coding, corporate compliance, quality, and finance to support Corporate Goals.
• Participates in the ongoing education of physicians, nurse practitioners, physician assistants and other healthcare team members to identify medical record documentation improvement opportunities employing conflict resolution skills as necessary.
• Utilizes critical thinking skills based upon extensive knowledge of disease processes and clinical outcomes to identify the need for further clarification of physician documentation within the medical record.
• Ensures that all written requests to physicians for additional documentation support Corporate Compliance policies.

Physical Requirements

Works in an office type setting, extensive walking throughout the facility. Prolonged periods of sitting reviewing medical records and documentation. Repetitive wrist motion and occasional lifting of 10-20 pounds. Intact sight and hearing with or without assistive devices are required. Ability to speak English fluently and write in understandable terms.

Education, Experience and Certifications

Registered Nurse North Carolina Licensure required. Bachelor’s Degree Required. Appropriate professional certification required within 3 years of hire date per department protocol. 5 years of related nursing experience preferred. Clinical experience within the assigned population. Extensive knowledge of disease processes and clinical outcomes. Case Management experience or background helpful. Strong financial and analytical skills preferred. Word, Outlook, Excel experience preferred.

Atrium Health Charlotte Job ID #1​5​6​4​4​3. Posted job title: Compliance Documentation Improvement Specialist (RN) Atrium Health Pineville Hybrid FT Days

Headquartered in Charlotte, NC, Atrium Health is now part of Advocate Health, the third-largest nonprofit, integrated health system in the United States, which was created from the combination with Advocate Aurora Health. In the Southeast Region, Atrium Health provides care under the Atrium Health name in Charlotte, NC, Atrium Health Wake Forest Baptist name in the Winston-Salem, NC, region, as well as Atrium Health Navicent and Atrium Health Floyd in Georgia and Alabama. Together, we are committed to providing equitable care for all. Annually, Advocate Health provides nearly $5 billion in community benefits.

Atrium Health Wake Forest Baptist

Atrium Health Wake Forest Baptist is a pre-eminent academic health system based in Winston-Salem, North Carolina. Atrium Health Wake Forest Baptist is part of Advocate Health, which is headquartered in Charlotte, North Carolina, and is the fifth-largest nonprofit health system in the United States, created from the combination of Atrium Health and Advocate Aurora Health. Atrium Health Wake Forest Baptist's two main components are an integrated clinical system - anchored by Atrium Health Wake Forest Baptist Medical Center, an 885-bed tertiary-care hospital in Winston-Salem - that includes Brenner Children's Hospital, five community hospitals, more than 300 primary and specialty care locations and more than 2,700 physicians; and Wake Forest School of Medicine, the academic core of Atrium Health Enterprise and a recognized leader in experiential medical education and groundbreaking research that includes Wake Forest Innovations, a commercialization enterprise focused on advancing health care through new medical technologies and biomedical discovery.

Atrium Health Navicent

Atrium Health Navicent is the leading provider of healthcare in central and south Georgia and is committed to its mission of elevating health and well-being through compassionate care. Atrium Health Navicent is part of Advocate Health, which is headquartered in Charlotte, North Carolina, and is the third-largest nonprofit health system in the United States, created from the combination of Atrium Health and Advocate Aurora Health. Atrium Health Navicent provides high-quality, personalized care in 53 specialties at more than 50 facilities throughout the region. As part of the largest, integrated, nonprofit health system in the Southeast, it is also able to tap into some of the nation's leading medical experts and specialists with Atrium Health, allowing it to provide the best care close to home - including advanced innovations in virtual medicine and care. Throughout its 125-year history in the community, Atrium Health Navicent has remained dedicated to enhancing health and wellness for individuals throughout the region through nationally recognized quality care, community health initiatives and collaborative partnerships. It is also one of the leading teaching hospitals in the region, helping to ensure viability for rural health care for the next generation. 

Atrium Health Floyd

Atrium Health Floyd Medical Center is a 304-bed, full-service hospital located in Rome, Georgia. Serving as the main campus for Atrium Health Floyd, this hospital provides a certified Chest Pain Center, a designated Bariatric Surgery Center of Excellence and a Breast Imaging Center of Excellence. Atrium Health Floyd also is home to a state-designated Level II Trauma Center and a Level III Neonatal Intensive Care Unit, and has specialty centers for pediatrics, and wound care and hyperbaric therapy.

• Medical benefits
• Vision benefits
• Dental benefits
• Life insurance
• 401k retirement plan
• Health savings account