Clinical Documentation RN | CDI Specialist

Jobtome; Corrales (NM); Sur place; USD 70 000 - 90 000; Plein temps

Avantages offerts par ce poste

Sign-On Bonus Available

Relocation Assistance Available

Résumé du poste

Jobtome in New Mexico seeks a Clinical Documentation Improvement (CDI) RN to review patient records during hospitalization, identify and record principal and secondary diagnoses, and support accurate DRG assignments.

You will educate physicians and staff on documentation requirements, coordinate with Health Information Management, utilize abstracting tools, and ensure HIPAA compliance while maintaining confidentiality.

Qualifications

• 1 year directly related experience in documentation improvement.
• RN licensure in NM (or as allowed by NM reciprocal agreement).
• Bachelor's degree preferred or equivalent education.

Responsabilités

• REVIEW and record principal and secondary diagnoses and assign a working MS-DRG.
• CONCURRENT REVIEW of admissions to initiate tracking and document findings.
• IDENTIFY and communicate documentation discrepancies to physicians and care teams.
• UTILIZE abstracting and data tools to perform coding, abstracting and reporting functions.
• EDUCATE providers on documentation requirements to improve severity of illness reporting.
• MAINTAIN confidentiality and adhere to HIPAA guidelines.
• Assist in reporting and analysis to support case-mix index and resource utilization.

Formation

Program Graduate

Bachelor's Degree

Description du poste

Jobtome in New Mexico seeks a Clinical Documentation Improvement (CDI) RN to review patient records during hospitalization, identify and record principal and secondary diagnoses, and support accurate DRG assignments.

You will educate physicians and staff on documentation requirements, coordinate with Health Information Management, utilize abstracting tools, and ensure HIPAA compliance while maintaining confidentiality.