Clinical Documentation RN: Elevate Medical Records Quality

CHRISTUS Health; Beaumont (TX); On-site; USD 85,000 - 105,000; Full time

Job summary

CHRISTUS Health is seeking a Clinical Documentation RN to improve the quality and completeness of medical record documentation and to support accurate DRG assignment. The role involves extensive interaction with physicians, patient caregivers, and health information management coding staff to ensure reimbursement reflects the services provided.

The position requires an Associate's Degree in Nursing and an active RN license in the state of employment or a compact licensure.

Qualifications

• RN licensure in state of employment or compact licensure.

Responsibilities

• Analyzes clinical status and identifies potential gaps in physician documentation.
• Communicates with attending physicians to validate observations and request more specific documentation.
• Works with HIM coding staff to ensure discharge diagnoses and co-morbidities reflect patient status.
• Maintains DRG worksheets and updates them with changes in inpatient status or procedures.
• Assists in data collection for hospital committees and designs tools to support documentation and reimbursement.

Education

Associate's Degree in Nursing

Job description

CHRISTUS Health is seeking a Clinical Documentation RN to improve the quality and completeness of medical record documentation and to support accurate DRG assignment. The role involves extensive interaction with physicians, patient caregivers, and health information management coding staff to ensure reimbursement reflects the services provided.

The position requires an Associate's Degree in Nursing and an active RN license in the state of employment or a compact licensure.