RN Clinical Documentation Specialist

Cone Health; Greensboro (NC); On-site; USD 70,000 - 90,000; Full time

Job summary

The RN Clinical Documentation Specialist at Cone Health in Greensboro NC uses nursing expertise to improve documentation quality in the medical record, collaborating with providers and a multidisciplinary team to ensure accurate DRG assignment and severity of illness scoring.

Responsibilities include initiating reviews, performing queries, supporting the Clinical Documentation Improvement Program, and maintaining strong interdepartmental relationships to meet departmental goals.

Qualifications

• 3 years of experience in clinical documentation or related CDI field.
• Bachelor's degree in nursing required; RN licensure in NC or compact state.

Responsibilities

• Initiates and performs documentation review to clarify conditions and procedures.
• Ensures correct MS-DRG assignment and SOI/ROM scoring, plus identification of Hospital Acquired Conditions.
• Performs appropriate query process and supports the CDI program.
• Develops and maintains effective working relationships with colleagues and multidisciplinary teams.
• Meets established departmental goals and performs other duties as assigned.

Skills

Clinical documentation

MS-DRG assignment

SOI/ROM scoring

Interdisciplinary collaboration

Education

Bachelor's Degree in Nursing

Job description

The RN Clinical Documentation Specialist is a clinical position using clinical/nursing knowledge of documentation requirements to improve overall quality and completeness of documentation in the patient's medical record using a multidisciplinary team approach. Works in collaborative effort with providers to ensure clinical information in the medical record is present and accurate, capturing the appropriate severity of illness and risk of mortality for the level of services provided and the appropriate DRG.

Essential Job Function:

• Initiates and performs documentation review (initial & follow up) of selected records to clarify conditions/diagnoses & procedures where inadequate or conflicting documentation exists in accordance with department standards.
• Ensures correct MS-DRG assignment, Severity of Illness (SOI)/risk of Mortality (ROM) scoring & identification of Hospital Acquired Conditions.
• Performs appropriate query process.
• Supports planning and educational processes of the Clinical Documentation Improvement Program.
• Develops and maintains effective working relationships with colleagues and communicates effectively with multidisciplinary teams.
• Meet established departmental goals/standards.
• Performs other duties as assigned.

Education:

• Required: Bachelor's Degree in Nursing.

Experience:

• Required: 3 years.

Licensure/Certification/Listing:

• Required: Registered Nurse licensed in NC or compact State Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Practitioner (CDIP), If not certified, CCDS or CDIP must be completed within 1 year after eligibility period met.