RN - Clinical Documentation Improvement Specialist

The Health Care Authority for Baptist Health, An Affiliate of UAB Health System; United States; On-site; USD 85,000 - 115,000; Full time

Job summary

Baptist Health is seeking an RN - Clinical Documentation Integrity Specialist to ensure the accuracy and completeness of provider-based documentation in the medical record. The role centers on coordinating with physicians, clinical staff and coding to optimize reimbursement and data quality.

Candidates must have RN licensure and strong analytical skills. Primary responsibilities include leading documentation improvement initiatives, drafting reports, and supporting regulatory and quality

Qualifications

• RN licensure active is required.
• Bachelor's degree in Nursing preferred.
• Minimum 2 years hospital clinical experience required.
• Experience with DRGs preferred.
• Knowledge of ICD and reimbursement methodologies a plus.

Responsibilities

• Facilitate integrity in clinical documentation in the medical record.
• Assess documentation by review and interaction with physicians, clinical staff, and coding staff.
• Ensure appropriate reimbursement is received for services rendered.
• Support profiling and reporting of outcomes with complete, accurate data.

Skills

Interpersonal skills

Analytical skills

Presentation skills

Team leadership

Problem solving

Education

Nursing degree (RN)

Bachelor's degree in Nursing

Tools

Microsoft Word

Microsoft Excel

Databases

Reporting tools

Graphs / charts

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)

Baptist Health is recognized by Forbes as one of America's best employers in the state of Alabama.