RN Clinical Documentation Specialist — Improve DRG Accuracy

Yale New Haven Health; New Haven (CT); On-site; USD 85,000 - 120,000; Full time

Job summary

Yale New Haven Health in New Haven, CT is seeking an Associate of Clinical Documentation Specialist to facilitate modifications to clinical documentation through real-time clinician interactions, ensuring accurate DRG and appropriate coding. The role requires an active RN license, BSN preferred, and at least three years of inpatient acute care experience; ICU experience is a plus.

You will collaborate with CDS and coding staff, maintain high audit scores, and contribute to quality measures

Qualifications

• Active RN license required.
• BSN preferred.

Responsibilities

• Review medical records to identify principal and secondary diagnoses, procedures, and assign a working DRG.
• Concurrently and retrospectively review charts to ensure DRG reflects diagnoses and comorbid conditions.
• Collaborate with coding staff to ensure documentation supports accurate coding.
• Develop strong professional relationships with CDS, Coding staff, physician leadership and clinicians.
• Use compliant query processes and document follow-up until closure.

Skills

Communication

Negotiation

Organizational skills

Adaptability

Data extraction

Willingness to learn

Third-party systems

Computer literacy

Software platforms

Collaboration

Independence

Flexibility

Detail-oriented

Education

RN license

BSN preferred

Tools

Electronic Health Records

Job description

Yale New Haven Health in New Haven, CT is seeking an Associate of Clinical Documentation Specialist to facilitate modifications to clinical documentation through real-time clinician interactions, ensuring accurate DRG and appropriate coding. The role requires an active RN license, BSN preferred, and at least three years of inpatient acute care experience; ICU experience is a plus.

You will collaborate with CDS and coding staff, maintain high audit scores, and contribute to quality measures