RN Clinical Documentation Specialist — Drive DRG Accuracy

Jobtome; Moriarty (NM); Sur place; USD 70 000 - 90 000; Plein temps

Avantages offerts par ce poste

Sign-On Bonus Available

Relocation Assistance Available

Résumé du poste

Jobtome in New Mexico is hiring a Documentation Improvement Specialist (RN) to review patient records during hospitalization, ensuring accurate coding and MS-DRG assignment. The role requires collaborating with physicians and care teams, providing education on documentation practices, and supporting hospital policy adherence.

Responsibilities include concurrent reviews, abstraction, and communication of findings to improve severity of illness reporting.

Qualifications

• 1 year directly related experience required.
• Experience in documentation improvement is a plus.
• RN license in NM or via reciprocal agreement required.

Responsabilités

• REVIEW: identify and record principal and secondary diagnoses and assign a working MS-DRG.
• CONCURRENT REVIEW: perform initial concurrent reviews for admissions and tracking.
• PROBLEM SOLVING: interpret clinical data and obtain documentation reflecting severity of illness.
• ABSTRACTS: track and report progress of the Documentation Improvement Program.
• COMMUNICATION: obtain/clarify diagnoses with physicians and staff.
• COORDINATION: coordinate with HIM, UR/Case Management, and quality teams.
• PROCESS IMPROVEMENT: develop and monitor improvement action plans.
• REPORTS: disseminate physician profiling reports.
• REPORT ANALYSIS: analyze documentation for severity and morbidity.
• EDUCATION: educate physicians and staff on queries and documentation practices.
• CONFIDENTIALITY: maintain HIPAA compliant handling of records.
• OTHER: perform additional duties as assigned.
• COMPLIANCE: ensure documentation supports severity and risk of mortality.

Connaissances

1 year related experience

Formation

Program Graduate

Nationally Accredited Nursing Graduate

Bachelor's Degree

Outils

RN licensure NM

HIPAA knowledge

Description du poste

Jobtome in New Mexico is hiring a Documentation Improvement Specialist (RN) to review patient records during hospitalization, ensuring accurate coding and MS-DRG assignment. The role requires collaborating with physicians and care teams, providing education on documentation practices, and supporting hospital policy adherence.

Responsibilities include concurrent reviews, abstraction, and communication of findings to improve severity of illness reporting.