Remote RN: Clinical Documentation & Compliance Expert

Presbyterian Healthcare Services; Santa Fe (NM); On-site; USD 66,000 - 112,000; Full time

Job summary

Presbyterian Healthcare Services is hiring an RN - Clinical Documentation and Compliance Specialist to support medical staff in accurate documentation for hospital services. The role is remote-based from Santa Fe, NM, with a weekday schedule and full-time employment.

The ideal candidate has an RN with 5 years clinical experience or a Bachelor’s in Nursing with CDI experience, seeks CCDS certification within 3 years, and demonstrates strong knowledge of ICD-10, CPT, HCPCS, DRG coding, and

Qualifications

• RN with required degree or bachelor’s in nursing with CDI experience
• CCDS certification to be achieved within 3 years of employment
• Knowledge of medical terminology and coding systems (ICD-10, CPT, HCPCS) and DRG concepts

Responsibilities

• Performs concurrent reviews of the medical record for inpatient admissions, assigns DRG and documents conditions
• Collaborates with Medical Staff, Nursing staff and other caregivers to improve chart documentation
• Assists physicians with documentation requirements to support medical necessity for hospital and physician billing
• Interprets clinical information and queries for supporting documentation in notes, histories, physicals, and consultations
• Initiates communication to physicians to obtain more specific diagnoses or comorbidities
• Acts as expert clinical resource for the HIM Coding team to meet regulatory requirements
• Coordinates with the HIM Coding team on coding guideline requirements
• Provides information and education to physicians not responding to queries on documentation requirements
• Maintains up-to-date knowledge of ICD-10, CPT, HCPCS, APC updates and CMS/JCAHO standards

Skills

Clinical documentation

Regulatory knowledge

Communication skills

Team collaboration

Query physicians

Education

Associate degree in Nursing

Bachelor's degree in Nursing

CCDS Certification (within 3 years)

Tools

ICD-10

CPT

HCPCS

DRG

Job description

Presbyterian Healthcare Services is hiring an RN - Clinical Documentation and Compliance Specialist to support medical staff in accurate documentation for hospital services. The role is remote-based from Santa Fe, NM, with a weekday schedule and full-time employment.

The ideal candidate has an RN with 5 years clinical experience or a Bachelor’s in Nursing with CDI experience, seeks CCDS certification within 3 years, and demonstrates strong knowledge of ICD-10, CPT, HCPCS, DRG coding, and