RN - Clinical Documentation Specialist - Day Shift

vacancy global pro; India; On-site; INR 8,111,000 - 10,496,000; Full time

Job summary

Christiana Care Hospital in Newark, DE seeks a RN Senior Clinical Documentation Specialist for day shift in a hybrid role with onsite requirements. The role focuses on improving documentation quality, supporting proper DRG assignment, and collaborating with physicians, coding staff, and HIMS on inpatient records.

Candidates should hold a DE RN license (or compact state) with 3+ years in acute care, and CCDS certification within one year of eligibility.

Qualifications

• DE RN licensed or Compact State license required.
• 3+ years of recent RN experience in acute care (Cardiac, Critical Care, Med-Surg, Oncology desirable).
• CCDS certification required within one year of eligibility.

Responsibilities

• Review inpatient records to identify documentation gaps.
• Educate and consult with physicians and staff to improve documentation.
• Support accurate DRG assignment and LOS goals.
• Participate in performance improvement activities.
• Maintain confidentiality and comply with HIPAA.
• Attend daily huddles with HIMS.

Skills

RN license

Healthcare documentation

Communication skills

Education

RN license

CCDS Certification

Job description

Job Details RN Senior Clinical Documentation Specialist Day Shift (Hours: M-F 8 hours) Hybrid position with onsite requirements. No Weekends or Holidays! Newark, DE Christiana Care Hospital is hiring a RN Clinical Documentation Specialist for improving the overall reputed company and completeness of clinical documentation (CDI) reputed company the inpatient medical record.

Primary Function:

Responsible to ensure that health care services are administered with reputed company, cost efficiency, and reputed company compliance, along with improving and ensuring the overall reputed company, cost efficiency and completeness of documentation reputed company the inpatient medical record. Ensure accuracy of documented diagnosis and support clinical indicators. Facilitate modifications to clinical documentation through extensive reputed company interaction with Physician Advisor, physicians, coding staff and other members of the reputed company team to support the appropriate reimbursement and clinical severity are captured compliantly for the level of service rendered to reputed company patients.

Scope, Purpose, And Frequency of Contacts:

Daily contact with Clinical Documentation Manager, HIMS/coding staff, Physician Advisor, and intradepartmental personnel. Frequent contact with physicians, physician's office staff, clinical, and ancillary departmental staff. Frequent contact with HIM Coding Management reputed company.

Duties & Responsibilities:

reputed company review of inpatient medical records throughout the patients hospitalization. Analyzes clinical status of patient, reputed company treatment, past medical history and identifies potential gaps in physician documentation. Communicate with physicians or other providers to validate diagnoses, clinical indicators and appropriate prompts for documentation, if necessary, either verbally or written. Demonstrates proficient knowledge of HIMS standards of coding and applies to ongoing evaluation of the medical record documentation. Educates physicians and other key reputed company providers regarding best reputed company clinical documentation and the need for accurate and complete documentation in the health record. Reviews and clarify clinical issues in the health record with the coding professionals that would support an accurate DRG assignment, severity of illness, and/or risk of mortality. Monitors patients reputed company consults with primary physician or designee and other members of the care delivery team at agreed-upon intervals, or more frequently, as needed. Participates in performance improvement activities regarding documentation improvement Maintains confidentiality of patients/members and staff information. Attends coding/financial/CDI educational programs and regulatory educational programs and updates as necessary to maintain a proficient knowledge reputed company. Reviews reputed company PSI encounters for completeness and accuracy. Review outcome with Physician Advisors, and Medical Directors, as needed. Attends daily huddles with HIMS to address any clinical concerns Computes a working DRG to identify the anticipated length of stay. Shared with the care team for LOS goals. Uses reputed company data to identify documentation opportunities and targeted physician education. Performs assigned work safely, adhering to established departmental safety rules and practices; reports to manager, in a reputed company manner, any unsafe activities, conditions, hazards, or safety violations that may cause injury to oneself, other employees, patients and visitors. Performs other reputed company duties as required.

Education and Experience Requirements:

DE RN licensed or Compact State. Minimum of 3 years recent experience as a Registered reputed company in acute care, adult care setting preferred. RN experience in Cardiac, Critical Care, Med-Surg, and Oncology experience highly desirable. Clinical Documentation, Case Management, Performance Improvement, or Inpatient Coding experience are highly desirable. Certified Clinical Documentation Specialist (CCDS) is required in a year after eligibility.

Knowledge, reputed company, And Ability:

Extensive knowledge of medical terminology, anatomy, physiology, pharmacology, and disease processes. Knowledge of nursing principles, practices, and processes. Knowledge of ICD-10 nomenclature, UHDDS and general coding principles. Knowledge of CMS, JCAHO and reputed company regulatory and reputed company requirements. Knowledge and ability to reputed company with the Health Insurance Portability and Accountability reputed company of 1996 (HIPAA) Knowledge of Performance Improvement Principles. Ability to work reputed company independently. Ability to collaborate with clinicians and administrative staff. Ability to utilize computer applications on various platforms. Ability to manage multiple reputed company with constant shifts in reputed company. Ability to plan and organize work assignments.

Physical Demands:

Prolonged daily rev