RN Clinical Documentation Specialist — Sign-On Bonus

Jobtome; Bernalillo (NM); Sur place; USD 65 000 - 95 000; Plein temps

Avantages offerts par ce poste

Sign-On Bonus Available

Relocation Assistance Available

Résumé du poste

Jobtome in Bernalillo, NM seeks a Nurse CDI professional to review inpatient documentation during hospitalization to support diagnoses and DRG accuracy. The role collaborates with physicians and care teams to ensure documentation reflects severity of illness and resource use.

The full-time CDI position requires an NM RN license and at least 1 year of related experience, with shift differentials and no direct patient care, focusing on training and compliance in a hospital setting.

Qualifications

• 1 year directly related experience
• RN in NM or as allowed by reciprocal agreement by NM

Responsabilités

• REVIEW principal/secondary diagnoses and assign MS-DRG; collaborate with physician, nurse, and CCS
• CONCURRENT REVIEW: perform initial and ongoing reviews for admissions and track findings
• PROBLEM SOLVING: interpret clinical data, evaluate meds/vital signs, suggest accurate diagnoses and obtain documentation
• ABSTRACTS: track progress using CDI program tools and report findings to HIM/QA/UR
• COMMUNICATION: obtain/clarify diagnoses or comorbidities with physicians; handle resistance professionally
• COORDINATION: coordinate with HIM, UR/Case Management, QA, physician leadership for accurate documentation
• PROCESS IMPROVEMENT: identify outcomes, develop and monitor improvement plans
• REPORTS: assist distribution of physician profiling reports from CDI software
• REPORT ANALYSIS: review documentation for severity of illness and report results
• EDUCATION: educate physicians and staff on queries and consequences of documentation
• CONFIDENTIALITY: maintain HIPAA compliance
• OTHER: perform additional duties as assigned
• COMPLIANCE: initiate queries to capture documentation supporting severity of illness and mortality risk

Formation

Bachelor's Degree

Nationally Accredited Nursing Graduate

Description du poste

Jobtome in Bernalillo, NM seeks a Nurse CDI professional to review inpatient documentation during hospitalization to support diagnoses and DRG accuracy. The role collaborates with physicians and care teams to ensure documentation reflects severity of illness and resource use.

The full-time CDI position requires an NM RN license and at least 1 year of related experience, with shift differentials and no direct patient care, focusing on training and compliance in a hospital setting.