RN Clinical Documentation Specialist - Elevate Care Records

University Of New Mexico - Hospitals; Moriarty (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 Jobs is seeking a Clinical Documentation Improvement (CDI) Specialist. This role performs concurrent review of hospital records to ensure accurate documentation supporting diagnoses and procedures, aiding DRG assignments. You will query physicians and coordinate with care teams to improve quality and case mix accuracy.

The position emphasizes training providers on documentation standards, using abstraction and coding tools, and maintaining HIPAA compliance. No patient care is required.

Qualifications

• Bachelor's degree required or equivalent in nursing.
• RN licensure in NM or via reciprocal agreement.
• Experience in clinical documentation improvement or related field preferred.

Responsabilités

• Review principal and secondary diagnoses and procedures and assign MS-DRG.
• Perform concurrent reviews to identify documentation gaps.
• Communicate preferred documentation with physicians to improve accuracy.
• Utilize CDI tools for abstraction, data entry, and reporting.
• Provide education to providers on documentation and coding guidelines.

Connaissances

Clinical documentation

Communication

MS-DRG understanding

Formation

Bachelor's Degree

Nationally Accredited Nursing Graduate

Program Graduate

Outils

MS-DRG worksheets

Coding guidelines

Description du poste

UNMH Jobs is seeking a Clinical Documentation Improvement (CDI) Specialist. This role performs concurrent review of hospital records to ensure accurate documentation supporting diagnoses and procedures, aiding DRG assignments. You will query physicians and coordinate with care teams to improve quality and case mix accuracy.

The position emphasizes training providers on documentation standards, using abstraction and coding tools, and maintaining HIPAA compliance. No patient care is required.