Clinical Documentation Specialist RN – CDI Expert

Marshall Health Network, Inc.; Huntington (VA); Presencial; USD 70.000 - 90.000; Jornada completa

Descripción de la vacante

St. Mary's Medical Center is seeking a Clinical Documentation Specialist RN to ensure accurate physician documentation and proper DRG assignment. This on-site role involves extensive chart review and collaboration with physicians, nurse practitioners, physician assistants, and HIM staff.

The successful candidate will query clinicians to obtain documentation, educate on clinical documentation improvement, and ensure medical necessity and chart completeness across patient records.

Formación

• Graduate of an approved school of nursing and possess RN licensure with WV licensure.
• BSN, RN, RHIA, RHIT, CCS, CCDS or CDI-P credentials preferred.
• Minimum two years acute care nursing experience or five years as Clinical Documentation Improvement Specialist with CCDS.
• Ability to use ICD-10/PCS coding and abstract information to support DRG assignment.
• Excellent written and verbal communication and critical thinking skills.

Responsabilidades

• Ensure accurate physician documentation to support DRG assignment.
• Query physicians and clinicians to obtain necessary documentation.
• Educate physicians on clinical documentation improvement and chart completeness.
• Collaborate with coding staff and HIM professionals to improve documentation quality.

Conocimientos

ICD-10/PCS coding

Chart abstraction

DRG assignment

Clinical documentation improvement

Communication skills

Medicare knowledge

Educación

RN license

AAS HIM

BSN

RHIA

RHIT

CCS

CCD S CDI-P

Herramientas

EMR systems

Descripción del empleo

St. Mary's Medical Center is seeking a Clinical Documentation Specialist RN to ensure accurate physician documentation and proper DRG assignment. This on-site role involves extensive chart review and collaboration with physicians, nurse practitioners, physician assistants, and HIM staff.

The successful candidate will query clinicians to obtain documentation, educate on clinical documentation improvement, and ensure medical necessity and chart completeness across patient records.