RN Clinical Documentation Specialist - Per Diem

CHRISTUS Health; Alexandria (LA); On-site; USD 65,000 - 86,000; Full time

Job summary

CHRISTUS Health in Louisiana is seeking a Clinical Documentation Registered Nurse to collaborate with physicians, nursing staff, and coding teams to enhance documentation quality for CMS reporting and reimbursement. You will identify documentation gaps, query physicians, and ensure accurate reflection of diagnoses and comorbidities to support DRG-based payment systems.

The role requires an RN license, an Associate's degree in Nursing, and experience in clinical documentation improvement.

Qualifications

• RN licensure in state of employment or compact licensure.
• Associates degree in nursing required.
• Experience in CDI or medical record review preferred.

Responsibilities

• Reviews inpatient records for identified payer populations within one business day of admission.
• Identifies documentation gaps with physicians and leaves queries to obtain complete documentation.
• Works with HIM coding staff to ensure discharge diagnoses and co-morbidities reflect patient status.
• Maintains a DRG worksheet to assist coders on documenting POA/HAC and procedures.
• Updates DRG worksheet when inpatient status/procedures change and consults physician for final diagnosis.
• Applies HIM coding standards to evaluate accuracy of physician documentation for acuity.
• Performs chart reviews on expired patients to assess severity and mortality risk for improvement activities.
• Develops education plans for physicians and staff on documentation and reimbursement and performance improvement.
• Collaborates with case management on LOS outside GMLOS to maximize reimbursement.
• Coordinates data collection and validation for public reporting initiatives for CMS and others.
• Maintains confidentiality at all times.
• Performs other duties as assigned.

Education

Associate's Degree in Nursing

Job description

CHRISTUS Health in Louisiana is seeking a Clinical Documentation Registered Nurse to collaborate with physicians, nursing staff, and coding teams to enhance documentation quality for CMS reporting and reimbursement. You will identify documentation gaps, query physicians, and ensure accurate reflection of diagnoses and comorbidities to support DRG-based payment systems.

The role requires an RN license, an Associate's degree in Nursing, and experience in clinical documentation improvement.