RN - Clinical Documentation Improvement Specialist

Baptist Health - Central Alabama; Montgomery (AL); On-site; USD 70,000 - 100,000; Full time

Job summary

Baptist Health - Central Alabama is seeking an RN - Clinical Documentation Improvement Specialist to strengthen the accuracy and completeness of clinical documentation across patient records. The role involves reviewing medical records, engaging with physicians and clinical staff, and ensuring appropriate reimbursement for services rendered.

The ideal candidate will hold an RN license, have at least 2 years of hospital clinical experience, and obtain CCDS certification within three years of

Qualifications

• Nursing degree required; CCDS certification required or obtained within 3 years of hire
• Minimum 2 years hospital clinical experience
• Experience with DRG’s preferred
• Active RN license required

Responsibilities

• Facilitate integrity in provider-based clinical documentation and ensure completeness of medical records
• Assess clinical documentation through chart reviews and interaction with physicians and clinical staff
• Ensure appropriate reimbursement for services and accuracy of reporting outcomes
• May have additional duties within scope of the role

Skills

Interpersonal skills

Analytical skills

Regulatory knowledge

Process improvement

Independent decision-making

Project management

Teaching/presentation

ICD and reimbursement knowledge

Education

Degree in Nursing

Bachelor's degree in Nursing

Tools

Microsoft Word

Microsoft Excel

Job description

Baptist Health is the largest healthcare system serving central Alabama, providing comprehensive hospital-based and outpatient services to nearly 60 percent of the residents in Montgomery, Autauga and Elmore counties.

To learn more about Baptist Health, visit us at https://www.baptistfirst.org.

Summary

The RN - Clinical Documentation Integrity Specialist shall be responsible to facilitate integrity in the overall quality and completeness of provider-based clinical documentation in the medical record. The Specialist will assess clinical documentation through extensive review of the medical record, interact with Physicians, clinical staff, and Coding staff to ensure that appropriate reimbursement is received for the level of services rendered to patients and that the clinical information utilized in profiling and reporting outcomes is complete and accurate. This position may have additional duties assigned that are within scope of the role.

Education / Experience

Degree in Nursing required, Bachelor's degree in Nursing preferred. Minimum 2 years hospital clinical experience required. Experience with DRG’s preferred.

License / Certification

Active RN license required, Certified Clinical Documentation Specialist (CCDS) required or obtained within 3 years of hire

Knowledge, Skills, And Abilities

• Proficient in use of Microsoft Word and Excel programs.
• Must possess advanced computer skills to maintain databases, spreadsheets and develop reporting tools/graphs/control charts.
• Regulatory survey coordination experience strongly preferred.
• Must have knowledge of accrediting and regulatory agencies procedures and standard requirements.
• Must have excellent interpersonal skills to interact with physicians and other professionals.
• Must have exceptional interpersonal communications, teaching/presentation and writing skills, analytical and strong team building skills.
• Experience in project management, group facilitation and leadership group presentations preferred.
• Must have knowledge of process improvement methodologies.
• Must be self-directed and highly motivated with problem solving abilities.
• Must possess independent decision-making skills.
• Exhibits a sufficient knowledge of clinical documentation requirements, DRG assignment, and clinical conditions or procedures.
• Extensive knowledge of ICD and reimbursement methodologies.

Primary Location

Corporate

Job

RN - Clinical Documentation Improvement Specialist

RN -- Clinical Documentation Integrity Specialist

Job Type

Regular-Full time

Shift

First Shift (United States of America)