Clinical Documentation RN II: Optimize Medical Records

Direct Jobs; Beaumont (TX); On-site; USD 70,000 - 100,000; Full time

Job summary

Direct Jobs is seeking a Clinical Documentation RN to improve the quality and completeness of inpatient medical record documentation. The role involves assessing records, guiding DRG assignments, and working with physicians, caregivers, and HIM staff to ensure appropriate reimbursement.

You will maintain DRG worksheets, drive documentation improvements, and educate clinical teams on opportunities for accurate coding and compliance. 8AM–5PM, full time, in Texas.

Qualifications

• RN licensed in the state of employment or a compact
• Experience with inpatient medical records and documentation improvement

Responsibilities

• Analyze patient clinical status, treatment plans, and history to identify documentation gaps.
• Communicate with attending physicians to validate observations and suggest detailed documentation improvements.
• Collaborate with nursing, physicians, and HIM staff to ensure complete reflection of patient status and co-morbidities.
• Maintain an electronic DRG worksheet to aid coders in identifying documented diagnoses and procedures.
• Update DRG worksheets for status changes and consult with physicians to finalize diagnoses.
• Design tools and lead education for clinical staff on documentation opportunities and reimbursement.
• Contribute data for analysis by medical committees and support performance improvement initiatives.

Skills

Clinical documentation

Interdisciplinary communication

DRG knowledge

Education

Associate's Degree in Nursing

Tools

HIM Coding systems

Job description

Direct Jobs is seeking a Clinical Documentation RN to improve the quality and completeness of inpatient medical record documentation. The role involves assessing records, guiding DRG assignments, and working with physicians, caregivers, and HIM staff to ensure appropriate reimbursement.

You will maintain DRG worksheets, drive documentation improvements, and educate clinical teams on opportunities for accurate coding and compliance. 8AM–5PM, full time, in Texas.