RN CDI Specialist — Elevate Medical Record Quality

Jobtome; Santa Fe (NM); Sur place; USD 80 000 - 110 000; Plein temps

Avantages offerts par ce poste

Sign-On Bonus Available

Relocation Assistance Available

Résumé du poste

Jobtome in Santa Fe, NM seeks a Clinical Documentation Improvement RN to review patient records in real time, identify documentation gaps, and collaborate with physicians to ensure accurate severity of illness and DRG assignment during hospitalization. This full-time role includes provider education, data abstraction, and clear communication of findings.

NM RN licensure and a Bachelor's degree are essential; about one year of related experience is preferred.

Qualifications

• RN license in NM or via reciprocal agreement.
• 1 year directly related experience.
• Documentation improvement experience is desirable.

Responsabilités

• REVIEW - Identify and record principal diagnoses, secondary diagnoses, procedures, and assign a working MS-DRG.
• CONCURRENT REVIEW - Conduct initial concurrent and ongoing re-reviews for selected admissions.
• PROBLEM SOLVING - Interpret clinical information and communicate with physicians to obtain accurate documentation.
• ABSTRACTS - Use monitoring tools to track progress of the Documentation Improvement Program.
• COMMUNICATION - Obtain/clarify specific diagnoses or comorbidities with physicians.
• COORDINATION - Facilitate communication among HIM, UR/Case Management, Quality Management, and physicians.
• PROCESS IMPROVEMENT - Develop and monitor process improvement action plans.
• REPORTS - Assist in distributing physician profiling reports.
• REPORT ANALYSIS - Review how documentation reflects severity of illness and report results to stakeholders.
• EDUCATION - Provide information to physicians and staff on queries and documentation.
• CONFIDENTIALITY - Maintain patient confidentiality per HIPAA.
• OTHER - Perform other duties as assigned.
• COMPLIANCE - Use query tools to capture documentation that supports illness severity and mortality risk.

Formation

Program Graduate

Bachelor's Degree

Nationally Accredited Nursing Graduate

Description du poste

Jobtome in Santa Fe, NM seeks a Clinical Documentation Improvement RN to review patient records in real time, identify documentation gaps, and collaborate with physicians to ensure accurate severity of illness and DRG assignment during hospitalization. This full-time role includes provider education, data abstraction, and clear communication of findings.

NM RN licensure and a Bachelor's degree are essential; about one year of related experience is preferred.