Clinical Documentation RN Specialist (CDI) – Sign-On Bonus

Jobtome; Rio Rancho (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 seeks a Registered Nurse with NM licensure for HIM Clinical Documentation Improvement to review inpatient records, identify principal and secondary diagnoses, and ensure documentation supports severity of illness and DRG assignments. You will query physicians, coordinate with care teams, and assist in documentation improvement initiatives during hospitalization.

The role emphasizes collaboration, education, and adherence to HIPAA while enabling process improvements and accurate coding

Qualifications

• Related Education and Experience may be substituted for one another on a year for year basis.

Responsabilités

• REVIEW - In collaboration with the physician, nurse, patient care coordinator, and certified coding specialist (CCS), identify and record principle diagnoses, secondary diagnoses, procedures, and assign a working MS-DRG
• CONCURRENT REVIEW - Conduct initial concurrent review and ongoing re-reviews for all selected admissions to initiate the tracking process, document findings on the MS-DRG worksheets, and identify other key quality indicators as appropriate
• PROBLEM SOLVING - Interpret clinical information in the medical record, evaluate medications, vital signs, surgical outcomes, etc. Identify potential diagnoses based on this information and communicate with physicians to obtain appropriate documentation that most accurately reflects patient severity of illness
• ABSTRACTS - Utilize monitoring tools to track the progress of the Documentation Improvement Program and identified quality indicator tracking elements, interpret tracking information and reports findings to the Health Information Management, Quality Management, and Utilization Review/Case Management meetings as requested
• COMMUNICATION - Communicate with physician to obtain/clarify specific principal diagnoses or comorbidities and complications; request clarification of existing documentation. Facilitate assertive, tactful communication when encountering resistance due to perception that information is adequately documented to achieve complete documentation per coding guidelines
• COORDINATION - Coordinate and facilitate communication between Health Information Management, Utilization Review/Case management, Quality Management, physician leadership to acquire, interpret, and transmit accurate diagnostic and procedure documentation. Inform Coding management of potential and/or actual problems

Formation

Program Graduate

Bachelor's Degree

Nationally Accredited Nursing Graduate

Nursing

1 year directly related experience

Documentation improvement

Description du poste

Jobtome seeks a Registered Nurse with NM licensure for HIM Clinical Documentation Improvement to review inpatient records, identify principal and secondary diagnoses, and ensure documentation supports severity of illness and DRG assignments. You will query physicians, coordinate with care teams, and assist in documentation improvement initiatives during hospitalization.

The role emphasizes collaboration, education, and adherence to HIPAA while enabling process improvements and accurate coding