Registered Nurse (RN) - Clinical Documentation Specialist, Remote

Dartmouth Health; United States; Remote; USD 75.000 - 95.000; Vollzeit

Benefits dieser Stelle

Loan repayment up to $20,000

Tuition reimbursement

Earned time plan

CEU/Training programs

Nursing Continuing Education Council资格

Zusammenfassung

Dartmouth Health is seeking a Clinical Documentation Specialist - RN, remote. This role focuses on improving the quality and completeness of medical record documentation and educating care teams on guidelines. CDI experience is preferred.

The position emphasizes working with coding staff to ensure accurate DRG assignments and compliant reimbursement, with ongoing education and performance improvement initiatives.

Qualifikationen

• Must create and maintain strong professional relationships.
• Excellent verbal and written communication abilities.
• Demonstrated interpersonal skills with negotiation and follow-up.
• Strong organizational skills with attention to detail.

Aufgaben

• Performs ongoing medical record reviews using documentation guidelines.
• Evaluates overall quality and completeness of clinical documentation.
• Conducts follow-up reviews of clinical documentation.
• Interacts with physicians and mid-level providers for detail in records.
• Ensures severity of illness and services are accurately reflected.
• Reviews patient clinical picture and assigns a working DRG.
• Tracks DRG related data and trends with documentation worksheets.
• Maintains system to track outcomes of documentation improvement.
• Prepares regular progress reports and presents findings.
• Participates in team meetings with Coding staff.
• Collaborates with inpatient coders to ensure correct DRG and reimbursement.
• Develops training programs for staff on documentation and coding.
• Provides updates on regulatory changes and clinical education.
• Educates Coding team on clinical updates; responds to payors as needed.
• Resolves outpatient issues involving physician documentation.
• Performs other duties as assigned.

Kenntnisse

Verbal communication

Written communication

Interpersonal skills

Organizational skills

Ausbildung

Licensed Registered Nurse

Jobbeschreibung

Overview

Clinical Documentation Specialist - RN, Remote

40 hours per week

Facilitates improvement in the overall quality, completeness and accuracy of medical record documentation. Educates members of the patient care team on documentation guidelines.

*CDI specific experience preferred

These are just a few highlights of being a nurse at Dartmouth Hitchcock Medical Center and Clinics:

• We have loan repayment up to $20,000.
• We offer generous tuition reimbursement.
• We have a very popular "earned time" plan.
• We have extensive CEU/Training programs.
• Our nurses serve as central figures in the success of our system through our shared governance nursing model.
• We offer a rigorous, research-focused environment.
• Dartmouth Hitchcock's Nursing Continuing Education Council is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center.

Why are we so unique? We are a nationally recognized Academic Medical Center set right in the middle of the White Mountains of New Hampshire.

Read more about Dartmouth Health and why YOU should work here.

The Dartmouth Health system stretches over New Hampshire and Vermont and offers the quintessential New England experience. With no income or sales tax, this beautiful area combines history, industry, and business and has been ranked consistently as one of the best places in the US to live and work. Anchored by the academic Dartmouth Hitchcock Medical Center in Lebanon, NH, the system includes the NCI-designated Dartmouth Cancer Center, Dartmouth Health Children’s; member hospitals, and 30 Dartmouth Hitchcock ambulatory clinics across the region.

Dartmouth Health is an equal opportunity employer, and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability status, veteran status, gender identity or expression, or any other characteristic protected by law.

Responsibilities

1. Performs ongoing medical record reviews using documentation improvement guidelines. Evaluates overall quality and completeness of clinical documentation. Conducts follow-up reviews of clinical documentation.
2. Initiates and maintains interactions with physicians and mid-level providers on a concurrent basis to address the need for more detailed information in the medical record.
3. Ensure the severity of illness and level of services provided are accurately reflected in the medical record.
4. Reviews clinical picture of the patient and assigns a working DRG. Ensures the working DRG is entered in the appropriate database/IDX system and trends completion of DRG worksheets.
5. Establishes and maintains a system to track and analyze outcomes of documentation improvement program. Prepares regular outcomes progress reports and presents.
6. Facilitates and participates in regular team meetings with the Coding staff.
7. Works with inpatient coders to ensure appropriate DRG assignment and that reimbursement reflects the level of services rendered.
8. Uses performance improvement methodologies and education strategies to develop formal training and improvement programs for the staff concerning clinical documentation opportunities, coding and reimbursement issues. Provides ongoing updates as regulations change.
9. Educates Coding team members on clinical (diagnostic and therapeutic) updates on an ongoing basis.
10. Utilizes nursing and clinical knowledge to respond to payors concerning clinical denials, as assigned
11. Provides clinical documentation expertise to assist in resolving outpatient issues involving physician documentation.
12. Performs other duties as required or assigned.

Qualifications

• Must have the ability to create and maintain strong relationships and confidently discuss clinical diagnoses.
• Excellent verbal and written communication abilities required.
• Demonstrated interpersonal skills, including negotiation, conflict resolution, follow-through and follow-up.
• Must have good organizational skill including project management, with attention to detail and accuracy.
• Must possess the ability to develop and deliver clinical education programs on clinical documentation improvement for the Medical Staff and Hospital Staff.
• Must have the following computer competencies: data entry and analysis, word processing, and presentations.
• Knowledge of DRG prospective payment systems, documentation & coding guidelines and compliance requirements preferred.
• Current knowledge of DRGs and payment regulations preferred.
• Up-to-date clinical knowledge, understand clinical picture of the patient condition and identify opportunities for improved documentation.
• 3 years of applicable experience.

Required Licensure/Certifications

• Licensed Registered Nurse with NH eligibility