RN Clinical Documentation Specialist — CDI Expert

University Of New Mexico - Hospitals; Rio Rancho (NM); Sur place; USD 65 000 - 85 000; Plein temps

Avantages offerts par ce poste

Sign-On Bonus Available

Relocation Assistance Available

Résumé du poste

UNMH seeks a Clinical Documentation Improvement Specialist to review patient records during hospitalization, ensuring complete documentation supports diagnoses, procedures, and resource use. You will interact with physicians to obtain clarifications and drive accuracy in severity of illness reporting.

Responsibilities include concurrent review, documentation tracking, and educating providers on documentation standards while coordinating with HIM, QA, and case management teams to optimize DRG

Qualifications

• RN license in NM or as allowed by reciprocal agreement by NM.
• Bachelor's Degree required.
• Nationally Accredited Nursing Graduate preferred.

Responsabilités

• Review principal and secondary diagnoses, procedures, and assign a working MS-DRG.
• Conduct concurrent reviews during admissions and track quality indicators.
• Communicate documentation findings with physicians and care team to improve severity of illness documentation.
• Utilize abstracting tools for coding, abstracting and reporting; support case mix index accuracy.
• Provide education to physicians and staff on documentation and coding requirements.
• Coordinate with HIM, Utilization Review, Quality Management and physician leadership to ensure accurate documentation.

Formation

RN license NM

Bachelor's Degree

Nationally Accredited Nursing Graduate

Description du poste

UNMH seeks a Clinical Documentation Improvement Specialist to review patient records during hospitalization, ensuring complete documentation supports diagnoses, procedures, and resource use. You will interact with physicians to obtain clarifications and drive accuracy in severity of illness reporting.

Responsibilities include concurrent review, documentation tracking, and educating providers on documentation standards while coordinating with HIM, QA, and case management teams to optimize DRG