Emergency Department CDI Nurse – Documentation & Coding

Hunterdon Health; Flemington (NJ); On-site; USD 93,077 - 116,347; Full time

Job summary

Hunterdon Health is seeking a Documentation Review Nurse to apply expertise in reviewing ED records for accuracy, completeness, and regulatory compliance, focusing on E/M Level coding and billing to support reimbursement. This full-time role requires an RN with an active license, at least three years of clinical nursing experience, and ED experience; BSN preferred.

You will collaborate with physicians, coders and IT to improve documentation and minimize denials.

Qualifications

• RN with an active and unencumbered license.
• BSN preferred.
• Minimum of three years of clinical nursing experience.
• Previous nursing experience in an emergency department.
• RN certification.

Responsibilities

• Clinical Documentation Review: Assess ED documentation to ensure accurate reflection of clinical presentation, diagnoses, and services.
• Coding Compliance: Verify documentation supports CPT, E/M Level and HCPCS codes for billing.
• Education and Feedback: Provide feedback to ED nursing staff to improve documentation clarity and compliance.
• Collaboration with Coders: Work with coding professionals to resolve discrepancies and clarify documentation.
• Regulatory Compliance: Ensure documentation aligns with regulatory and payor requirements.
• Performance Metrics: Track nursing documentation trends to improve reimbursement and reduce denials.
• Continuous Learning: Stay updated on E/M coding guidelines and payor requirements.
• HIPAA Compliance: Maintain strict HIPAA compliance and confidentiality.
• Data quality issues: Collaborate with IT and revenue cycle teams to resolve data quality issues.
• Other duties as assigned: support the unit and health system.

Job description

Hunterdon Health is seeking a Documentation Review Nurse to apply expertise in reviewing ED records for accuracy, completeness, and regulatory compliance, focusing on E/M Level coding and billing to support reimbursement. This full-time role requires an RN with an active license, at least three years of clinical nursing experience, and ED experience; BSN preferred.

You will collaborate with physicians, coders and IT to improve documentation and minimize denials.