Registered Nurse, Clinical Documentation Specialist CDIP, CCDS

vacancy global pro; India; On-site; INR 800,000 - 1,600,000; Full time

Benefits offered by this job

Health insurance

401(k) matching

Paid time off

Flexible work hours

Professional development opportunities

Job summary

vacancy global pro is seeking a Nurse Documentation Specialist to improve and verify clinical documentation quality. You will engage physicians, nurses, and coding staff to ensure accurate DRG assignment and proper reimbursement.

The role emphasizes leadership in documentation, adherence to CDMP guidelines, and ongoing education across the patient care team, with a focus on compliance and efficiency.

Qualifications

• Current RN licensure in the organization.
• Associates Degree required.
• Minimum of five years in professional nursing practice.
• CCD S or CDIP certifications preferred.
• Bachelor's Degree in Nursing preferred.
• Additional education in Finance, healthcare regulations, and diagnoses-procedure coding preferred.
• Experience in healthcare utilization and revenue management preferred.
• Working knowledge of DRG coding optimization strategies and clinical documentation requirements.
• Familiar with ICD-10 coding conventions, anatomy and physiology, medical terminology, MSDRG reimbursement, coding software.

Responsibilities

• Improving the overall quality and completeness of clinical documentation
• Modifying clinical documentation through interaction with physicians, nursing staff, and medical records coding staff
• Ensuring appropriate reimbursement is received for services rendered
• Educating all patient care team members on clinical documentation
• Conducting admission/continued stay reviews using CDMP guidelines
• Monitoring documentation against core measure quality indicators and addressing non-compliant documentation
• Collaborating with coding staff to assign the working DRG to contribute for rounds
• Maintaining a leadership role to ensure compliant documentation
• Organizing and performing work effectively and efficiently

Skills

Analytical thinking

Problem-solving

Written communication

Verbal communication

Leadership

Education

Associate degree

Bachelor's degree in Nursing

CCDS/CDIP certifications

Tools

Coding software

ICD-10 coding conventions knowledge

Job description

Job Description:

• Improving the overall quality and completeness of clinical documentation
• Modifying clinical documentation through interaction with Physicians, Nursing staff, other patient caregivers, and medical records coding staff
• Ensuring appropriate reimbursement is received for services rendered
• Educating all members of the patient care team on clinical documentation
• Conducting admission/continued stay reviews using the Compliant Documentation Program Management (CDMP) guidelines
• Monitoring documentation against "core measure" quality indicators and addressing non-compliance documentation
• Collaborating with coding staff to assign the "working" DRG to contribute for reputed company Rounds
• Maintaining a leadership role to ensure compliant documentation
• Organizing and performing work effectively and efficiently

Requirements:

• Current RN Licensure in the reputed company
• Associates Degree
• Minimum of five (5) years in the practice of professional nursing
• CCDS or CDIP certifications preferred
• Bachelor's Degree in Nursing preferred
• Additional education in Finance, Healthcare regulations, and diagnoses-procedure coding preferred
• Experience in Healthcare Utilization and Revenue Management preferred
• Working knowledge of DRG coding optimization strategies and clinical documentation requirements
• Familiar with ICD10 coding conventions, anatomy and physiology, medical terminology, MSDRG reimbursement, coding software
• Excellent analytical thinking, problem-solving abilities, and written and verbal communication skills

Benefits:

• Health insurance
• 401(k) matching
• Paid time off
• Flexible work hours
• Professional development opportunities