Clinical Documentation Specialist RN – CDI & Education

Jobtome; Peralta (NM); Sur place; USD 75 000 - 105 000; Plein temps

Avantages offerts par ce poste

Sign-On Bonus Available

Relocation Assistance Available

Résumé du poste

Jobtome in New Mexico is seeking a Clinical Documentation Improvement Specialist in the HIM Clinical Documentation department. This role focuses on concurrent review of medical records to support diagnoses, contribute to severity/mortality profiles, and improve documentation accuracy without direct patient care.

You will collaborate with physicians, nurses, and coding colleagues, utilize MS-DRG worksheets, and provide ongoing training on documentation standards to enhance coding quality and

Qualifications

• Related Education and Experience may be substituted for one another on a year for year basis.
• Essential: Program Graduate; Nonessential: Bachelor's Degree.
• Essential: RN in NM or as allowed by reciprocal NM agreement.

Responsabilités

• REVIEW with physician, nurse, and CCS to identify diagnoses and assign a working MS-DRG.
• CONCURRENT REVIEW of admissions to document findings and track quality indicators.
• PROBLEM SOLVING to interpret clinical data and obtain accurate documentation.
• ABSTRACTS using software tools to support documentation and reporting.
• COMMUNICATION with physicians to obtain/clarify diagnoses and comorbidities.
• COORDINATION between HIM, Utilization Review, and Quality Management.
• PROCESS IMPROVEMENT by developing action plans and monitoring outcomes.
• REPORTS and REPORT ANALYSIS to share physician profiling results.
• EDUCATION to train providers on documentation and coding guidelines.
• CONFIDENTIALITY per HIPAA; OTHER duties as assigned.

Formation

Program Graduate

Bachelor's Degree

Outils

MS-DRG worksheets

Description du poste

Jobtome in New Mexico is seeking a Clinical Documentation Improvement Specialist in the HIM Clinical Documentation department. This role focuses on concurrent review of medical records to support diagnoses, contribute to severity/mortality profiles, and improve documentation accuracy without direct patient care.

You will collaborate with physicians, nurses, and coding colleagues, utilize MS-DRG worksheets, and provide ongoing training on documentation standards to enhance coding quality and