RN Clinical Documentation Specialist — Elevate Medical Records

Jobtome; Edgewood (KY); On-site; USD 75,000 - 90,000; Full time

Benefits offered by this job

Sign-On Bonus Available

Relocation Assistance Available

Job summary

Jobtome is seeking a Documentation Improvement Specialist for a full-time, dayshift role in Kentucky. The incumbent will review clinical documentation during patient stays to support diagnoses, procedures, and MS-DRG assignments, providing feedback to physicians and care teams to improve severity of illness representations.

Role emphasizes training providers, data abstraction, and participation in the Clinical Documentation Improvement Program, with no direct patient care duties.

Qualifications

• Relevant degree in health information management or nursing related field.
• Experience in documentation improvement or medical coding beneficial.
• Ability to collaborate with physicians and care teams.

Responsibilities

• Review and document principal and secondary diagnoses and procedures with physicians and CCS.
• Perform concurrent review during hospitalization to support MS-DRG assignment and severity of illness.
• Communicate findings and obtain clarifications to ensure complete documentation.
• Utilize abstracting software for coding, abstraction, and reporting.
• Educate providers on documentation requirements and coding guidelines.
• Maintain confidentiality per HIPAA; comply with policies and procedures.
• Support process improvement and reporting for the Clinical Documentation Improvement Program.

Education

Program Graduate

Bachelor's Degree

Job description

Jobtome is seeking a Documentation Improvement Specialist for a full-time, dayshift role in Kentucky. The incumbent will review clinical documentation during patient stays to support diagnoses, procedures, and MS-DRG assignments, providing feedback to physicians and care teams to improve severity of illness representations.

Role emphasizes training providers, data abstraction, and participation in the Clinical Documentation Improvement Program, with no direct patient care duties.