Clinical Documentation Specialist - Registered Nurse

Healthcare Support Staffing; Moreno Valley (CA); On-site; USD 75,000 - 90,000; Full time

Benefits offered by this job

Excellent pay

Opportunity at a large local hospital system

Immediate hiring

Job summary

A national healthcare recruiting firm is seeking a Clinical Documentation Specialist - Registered Nurse in Moreno Valley, California. The role involves reviewing in-house Medicare cases and ensuring accurate clinical documentation. Candidates must have clinical experience in an acute care setting and knowledge of ICD-9 CM & CPT-4 coding. Excellent pay and immediate hiring opportunity at a large local hospital system. Join a dedicated team to improve documentation practices and achieve quality goals.

Qualifications

• Clinical experience in an acute care environment is required.
• Experience in nursing health information or clinical documentation is required.
• Ability to analyze large amounts of data is essential.

Responsibilities

• Review in-house Medicare cases and identify working DRG using the 3M encoder.
• Ensure patient record contains clear and accurate clinical documentation.
• Work with physician clinical documentation and coding processes.

Skills

Knowledge of diagnoses/procedures according to ICD-9 CM & CPT-4

Problem-solving ability

Ability to multi-task

Proficient computer skills

Education

Current CDI certification (must obtain within 18 months)

Tools

Charting software

MS Office Suite

Lotus Notes

Job description

Clinical Documentation Specialist - Registered Nurse

Contract

HealthCare Support Staffing, Inc. (HSS), is a proven industry-leading national healthcare recruiting and staffing firm. HSS has a proven history of placing talented healthcare professionals in clinical and non-clinical positions with some of the largest and most prestigious healthcare facilities including: Fortune 100 Health Plans, Mail Order Pharmacies, Medical Billing Centers, Hospitals, Laboratories, Surgery Centers, Private Practices, and many other healthcare facilities throughout the United States. HealthCare Support Staffing maintains strong relationships with top providers in healthcare and can assure healthcare professionals they will receive fast access to great career opportunities that best fit their expertise. Connect with one of our Professional Recruiting Consultants today to see how a conversation can turn into a long-lasting and rewarding career!

• CDI Registered Nurse will be working onsite at the Hospital.
• Registered nurses will review our in-house Medicare cases. We will need them to identify the working DRG using the 3M encoder, write queries, do follow-up, and resolve any questions.
• The CDI Specialist is an integral part of the healthcare team and is responsible for ensuring that the patient record contains clinical documentation that is clear, concise, and clinically accurate to meet the goals of the CDI program. The CDI Specialist serves as part of the team responsible for improving the concurrent documentation practices in the hospital through ongoing education and works with physician clinical documentation, coding and reimbursement processes towards achieving quality and productivity goals.
• Knowledge of diagnoses/procedures in accordance with ICD-9 CM & CPT-4 coding principles.
• Knowledge of all state, federal and private reimbursement systems.
• Ability to analyze large amounts of date, and be a problem solver.
• Ability to multi-task.
• Clinical experience in acute care environment- Required.
• Experience in practice of clinical documentation; nursing health information, case management, quality management or similar related fields – Required.
• Proficient in computer skills with many softwares including, but not limited to, charting softwares, MS Office Suite, Lotus Notes- Required.
• Current CDI certification (must obtain within 18 months of employment through Association of Clinical Documentation Improvement Specialist/ACDIS)- Highly Desired.

Excellent pay and opportunity at a large local hospital system. Interviewing and hiring right away.