RN CDI Specialist — Clinical Documentation

Jobtome; Placitas (NM); Sur place; USD 65 000 - 85 000; Plein temps

Avantages offerts par ce poste

Sign-On Bonus Available

Relocation Assistance Available

Résumé du poste

Jobtome in Placitas, NM seeks a Clinical Documentation Improvement professional to review inpatient records and ensure accurate coding, severity of illness, and DRG assignment. You will collaborate with physicians and care teams to obtain precise documentation during hospitalization and support program metrics.

Responsibilities include concurrent reviews, data abstraction, education of providers, and ongoing process improvement. NM RN licensure and CDI/CCS credentials are preferred.

Qualifications

• Related education and experience may be substituted for one another on a year for year basis.
• RN licensure in NM or via reciprocal agreement is required.
• Certification in coding or documentation improvement is a plus.

Responsabilités

• REVIEW: identify and record principal and secondary diagnoses and procedures, assign MS-DRG.
• CONCURRENT REVIEW: conduct initial and ongoing reviews to track inputs and quality indicators.
• PROBLEM SOLVING: interpret clinical data and obtain documentation reflecting severity of illness.
• ABSTRACTS: use tools to track Documentation Improvement Program metrics and reports.
• COMMUNICATION: obtain/clarify diagnoses with physicians and colleagues.
• COORDINATION: liaise with HIM, Utilization Review, Quality Management and physician leadership.
• PROCESS IMPROVEMENT: develop and monitor improvement plans.
• REPORTS: assist in sharing physician profiling reports.
• REPORT ANALYSIS: assess documentation to reflect severity of illness; present findings.
• EDUCATION: train providers and staff on documentation best practices.
• CONFIDENTIALITY: maintain HIPAA-compliant handling of records.
• OTHER: perform additional duties as assigned.
• COMPLIANCE: ensure documentation supports severity of illness and risk of mortality.

Formation

Program Graduate

Bachelor's Degree

Nationally Accredited Nursing Graduate

Nursing

RN in NM

Certified Coding Specialist

CDIP or CDIS

1 year directly related experience

Description du poste

Jobtome in Placitas, NM seeks a Clinical Documentation Improvement professional to review inpatient records and ensure accurate coding, severity of illness, and DRG assignment. You will collaborate with physicians and care teams to obtain precise documentation during hospitalization and support program metrics.

Responsibilities include concurrent reviews, data abstraction, education of providers, and ongoing process improvement. NM RN licensure and CDI/CCS credentials are preferred.