RN - Clinical Documentation Improvement Specialist

Baptist Health; United States; Hybrid; USD 80,000 - 100,000; Full time

Job summary

Baptist Health is seeking an RN - Clinical Documentation Improvement Specialist to ensure accuracy and completeness of provider documentation for optimal reimbursement. The role involves reviewing records, collaborating with physicians and coding staff, and driving quality improvement across clinical documentation.

Ideal candidates hold an RN license, a nursing degree, and CCDS credentials or plans to obtain within 3 years. Hospital CDI experience and DRG familiarity are highly valued.

Qualifications

• Degree in Nursing required.
• Bachelor's degree in Nursing preferred.
• Minimum 2 years hospital clinical experience required.
• Experience with DRG’s preferred.
• Active RN license required.
• Certified Clinical Documentation Specialist (CCDS) required or obtained within 3 years of hire.

Responsibilities

• Facilitate integrity in provider-based clinical documentation in the medical record.
• Review medical records to assess documentation quality and completeness.
• Interact with physicians, clinical staff, and coding staff to ensure appropriate reimbursement.
• Support reporting and profiling of outcomes based on clinical data.
• May have additional duties within the scope of the role.

Skills

Word & Excel

Data analysis

Interpersonal skills

Communication

Process improvement

Project management

Problem solving

Independent decision-making

ICD & reimbursement knowledge

Education

Nursing degree

Bachelor’s degree in Nursing

Active RN license

CCDS certification or eligible

Tools

Microsoft Word

Microsoft Excel

Reporting tools

Job description

RN - Clinical Documentation Improvement Specialist# Careers## RN - Clinical Documentation Improvement SpecialistApply: 2- Hybrid: Corporate: Full time: Posted Today: JR107670Baptist 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.**Highlights:****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 SpecialistRN -- Clinical Documentation Integrity Specialist**Job Type:**Regular-Full time**Shift**:First Shift (United States of America)