RN Clinical Documentation Specialist - Elevate Records

UNM Hospital; Albuquerque (NM); On-site; USD 75,000 - 95,000; Full time

Benefits offered by this job

Sign-On Bonus Available

Relocation Assistance Available

Job summary

UNM Hospital in Albuquerque, NM seeks a Clinical Documentation Improvement professional to review and enhance documentation during hospitalization. You will collaborate with physicians, nurses, and coders to improve accuracy of diagnoses and procedures, supporting appropriate coding and DRG assignment.

The role emphasizes real-time queries, education of providers, and coordination across departments to ensure compliant, accurate documentation while maintaining patient confidentiality and quality

Qualifications

• RN licensed in NM or per reciprocal agreement.
• 1 year directly related experience in clinical documentation improvement.
• Bachelor's degree or higher; nursing specialization is preferred.

Responsibilities

• REVIEW - identify and record principal and secondary diagnoses and assign working MS-DRG.
• CONCURRENT REVIEW - perform initial and ongoing reviews for admissions; document findings.
• PROBLEM SOLVING - interpret clinical data and obtain documentation reflecting severity of illness.
• ABSTRACTS - track progress and report to HIM, QA, and Utilization Review.
• COMMUNICATION - obtain/clarify diagnoses with physicians; educate on documentation needs.
• COORDINATION - liaise between HIM, Utilization Review, QA, and leadership.
• PROCESS IMPROVEMENT - develop and monitor improvement plans.
• REPORTS - support distribution of physician profiling reports.
• REPORT ANALYSIS - analyze documentation to reflect severity and outcomes.
• EDUCATION - provide guidance to physicians and staff on queries and documentation.
• CONFIDENTIALITY - maintain patient confidentiality per HIPAA.
• OTHER - perform additional duties as assigned.
• COMPLIANCE - initiate clarifications via query tools to capture accurate documentation.

Skills

Clinical documentation improvement

Communication with physicians

HIPAA compliance

Education

RN licensure in NM

Bachelor's Degree

Nationally Accredited Nursing Graduate

Tools

Documentation software

MS-DRG worksheets

Job description

UNM Hospital in Albuquerque, NM seeks a Clinical Documentation Improvement professional to review and enhance documentation during hospitalization. You will collaborate with physicians, nurses, and coders to improve accuracy of diagnoses and procedures, supporting appropriate coding and DRG assignment.

The role emphasizes real-time queries, education of providers, and coordination across departments to ensure compliant, accurate documentation while maintaining patient confidentiality and quality