Clinical Documentation Improvement RN Leader

University Health; Boerne (TX); On-site; USD 75,000 - 105,000; Full time

Job summary

University Health in Texas is seeking a Clinical Documentation Improvement Nurse to ensure accurate and complete documentation for inpatients. You will review patient charts, query providers, and collaborate with the care team to reflect ROM and SOI for optimum reimbursement.

Requirements include a bachelor's degree in nursing, Texas RN license, and several years hospital experience; completion of a Clinical Documentation Improvement course within hire date.

Qualifications

• Bachelor's degree in nursing preferred.
• Three years recent, full-time hospital experience preferred.
• Work experience in documentation improvement, case management, utilization review or hospital quality assurance preferred.
• Must complete a Clinical Documentation Improvement Course within specified time of hire date.

Responsibilities

• Review inpatient charts to ensure accurate and complete documentation.
• Query providers to ensure complete documentation in the medical record.
• Collaborate with the care team to reflect ROM and SOI for appropriate reimbursement.
• Maintain knowledge of coding guidelines, ACDIS standards, Epic workflows, and 3M principles.

Skills

Clinical Documentation Improvement

Education

Bachelor's degree in nursing

RN license

Job description

University Health in Texas is seeking a Clinical Documentation Improvement Nurse to ensure accurate and complete documentation for inpatients. You will review patient charts, query providers, and collaborate with the care team to reflect ROM and SOI for optimum reimbursement.

Requirements include a bachelor's degree in nursing, Texas RN license, and several years hospital experience; completion of a Clinical Documentation Improvement course within hire date.