RN - Clinical Documentation Improvement Specialist

Baptist Health; United States; On-site; USD 75,000 - 110,000; Full time

Job summary

Baptist Health, the region's leading healthcare system, seeks an RN - Clinical Documentation Improvement Specialist to ensure complete and accurate provider-based documentation across medical records. You will review records, collaborate with physicians and staff, and support appropriate reimbursement and outcome reporting.

The role requires an active RN license, a CCDS certification or plan to obtain within 3 years, and strong data skills to develop reporting tools and drive process

Qualifications

• Requires nursing degree and active RN license.
• CCDS certification or plan to obtain within 3 years is required or pursued.
• Strong data, reporting, and process-improvement skills are essential.

Responsibilities

• Facilitate integrity and completeness of provider-based clinical documentation.
• Review medical records to ensure appropriate reimbursement for services rendered.
• Collaborate with physicians, clinical staff and coding staff to improve documentation quality.
• Develop reporting tools, graphs, and control charts to support outcomes profiling.

Skills

Microsoft Word

Excel

Data analysis

Interpersonal skills

Project management

Regulatory knowledge

Education

Bachelor's degree in Nursing

Active RN license

CCDS certification or plan to obtain within 3 years

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.

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 Specialist

RN – Clinical Documentation Integrity Specialist

Job Type:

Regular-Full time

Shift:

First Shift (United States of America)