RN Clinical Documentation Specialist CDI Expert Relocation

University Of New Mexico - Hospitals; Bernalillo (NM); Sur place; USD 70 000 - 95 000; Plein temps

Avantages offerts par ce poste

Sign-On Bonus Available

Relocation Assistance Available

Résumé du poste

UNMH Jobs is seeking a Clinical Documentation Improvement professional in New Mexico. The role focuses on concurrent review of medical records to ensure complete documentation supports diagnoses, procedures, and resource use.

You will query physicians as needed and coordinate with HIM and Case Management to maintain accurate case mix index and DRG assignments. Responsibilities include reviewing records during hospitalization, abstracting data for reporting, and educating providers on

Qualifications

• RN licensed in NM or via reciprocal agreement.
• 1 year directly related experience required.
• Documentation improvement experience preferred.

Responsabilités

• REVIEW – identify and record principal and secondary diagnoses, procedures and assign a working MS-DRG.
• CONCURRENT REVIEW – conduct initial and ongoing re-reviews for admissions.
• PROBLEM SOLVING – interpret clinical data and obtain accurate documentation reflecting illness severity.
• ABSTRACTS – track progress and report findings to HIM, Quality Management and Utilization/Case Management.
• COMMUNICATION – obtain/clarify diagnoses and comorbidities with physicians.
• COORDINATION – liaise among HIM, Utilization Review, Quality Management and physician leadership.
• PROCESS IMPROVEMENT – develop and implement process improvements and monitor results.
• REPORTS – assist in distributing physician profiling reports.
• REPORT ANALYSIS – analyze how documentation reflects severity of illness.
• EDUCATION – provide education to physicians and staff about queries and documentation.

Connaissances

Documentation review

Concurrent review

Query communication

Coordination

Process improvement

Reports & analysis

Education

Formation

Bachelor's Degree

Nationally Accredited Nursing Graduate

Program Graduate

Outils

MS-DRG worksheets

Documentation software tools

Description du poste

UNMH Jobs is seeking a Clinical Documentation Improvement professional in New Mexico. The role focuses on concurrent review of medical records to ensure complete documentation supports diagnoses, procedures, and resource use.

You will query physicians as needed and coordinate with HIM and Case Management to maintain accurate case mix index and DRG assignments. Responsibilities include reviewing records during hospitalization, abstracting data for reporting, and educating providers on