RN CDI Specialist: Elevate Clinical Documentation & DRG

St. Mary's Medical Center Inc; Huntington (WV); On-site; USD 85,000 - 100,000; Full time

Job summary

St. Mary's Medical Center is seeking a Clinical Documentation Specialist RN for an on-site role to ensure accurate documentation in patient records to support DRG assignments and proper severity representation.

You will review charts, query clinicians, and educate staff on CDI matters to improve documentation quality. Requirements include RN with WV licensure, AAS in HIM, and 2+ years acute care nursing experience or 5 years as a CDI with CCDS credential.

Qualifications

• Graduate of an approved nursing program (LPN or RN) and/or possess an AAS in HIM from an AHIMA accredited program.
• RN must have and maintain a current WV licensure.
• BSN, RN, RHIA, RHIT, CCS, CCDS, CDI-P, or combination thereof, preferred.
• A minimum of two years experience in acute care nursing and/or 5 years previous experience as Clinical Documentation Improvement Specialist with CCDS credential.
• Ability to use ICD-10 and PCS coding systems, abstract information from charts and apply appropriate DRG.
• Knowledge of care delivery documentation systems and related medical record documents.
• Strong clinical knowledge and pathology/physiology; excellent written and verbal communication; critical thinking.
• Knowledge of inpatient admission criteria; ability to work independently; computer literacy; familiarity with Medicare reimbursement.

Responsibilities

• Review medical records to ensure accurate documentation supporting DRG assignment.
• Query physicians and clinicians to obtain clarifications or additional documentation.
• Educate physicians on clinical documentation improvement matters and documentation standards.
• Communicate findings to coding staff and HIM professionals to ensure accurate patient representation.

Skills

ICD-10/PCS coding

Chart abstraction

DRG assignment

Medical record review

Clinical communication

Critical thinking

Inpatient criteria knowledge

Independence in time management

Computer literacy

Medicare knowledge

Education

RN with WV licensure

AAS in HIM

BSN/RHIA/RHIT/CCDS/CDI-P preferred

Tools

AHIMA accredited program

Job description

St. Mary's Medical Center is seeking a Clinical Documentation Specialist RN for an on-site role to ensure accurate documentation in patient records to support DRG assignments and proper severity representation.

You will review charts, query clinicians, and educate staff on CDI matters to improve documentation quality. Requirements include RN with WV licensure, AAS in HIM, and 2+ years acute care nursing experience or 5 years as a CDI with CCDS credential.