Clinical Documentation RN Specialist - DRG & Severity Focus

University Of New Mexico - Hospitals; Albuquerque (NM); Sur place; USD 70 000 - 90 000; Plein temps

Résumé du poste

UNMH in Albuquerque, NM is seeking a Clinical Documentation Improvement professional to lead concurrent review and documentation optimization for accurate MS-DRG assignment. You will collaborate with physicians and care teams to ensure complete and accurate coding and reporting of diagnoses and procedures.

The role emphasizes education, data abstraction, and compliance with HIPAA, with a focus on improving severity of illness representations and hospital metrics.

Qualifications

• Active NM RN license is required.
• Bachelor's degree or higher in nursing or health information field.
• 1 year of directly related experience in clinical documentation.
• CDIP/CDIS is a plus.

Responsabilités

• REVIEW patient records with physicians to identify principal and secondary diagnoses.
• CONCURRENT REVIEW of admissions and documentation to support MS-DRG assignment.
• Communicate queries to physicians to improve documentation accuracy.
• Utilize abstracting tools for coding, reporting and trend analysis.
• Provide education to providers on documentation improvements as needed.
• Maintain confidentiality per HIPAA and hospital policies.

Connaissances

Attention to detail

Medical terminology

Documentation improvement

Formation

RN license in NM

Bachelor's Degree

Nationally Accredited Nursing Graduate

CDIP/CDIS

Certified Coding Specialist

Description du poste

UNMH in Albuquerque, NM is seeking a Clinical Documentation Improvement professional to lead concurrent review and documentation optimization for accurate MS-DRG assignment. You will collaborate with physicians and care teams to ensure complete and accurate coding and reporting of diagnoses and procedures.

The role emphasizes education, data abstraction, and compliance with HIPAA, with a focus on improving severity of illness representations and hospital metrics.