RN Clinical Documentation Specialist — Sign-On Bonus & Relocation

University Of New Mexico - Hospitals; Peralta (NM); Sur place; USD 65 000 - 90 000; Plein temps

Avantages offerts par ce poste

Sign-On Bonus Available

Relocation Assistance Available

Résumé du poste

UNMH is seeking a Clinical Documentation Specialist to review and improve inpatient documentation during patient stays. You will collaborate with physicians and care teams to ensure documentation aligns with diagnoses, procedures, and MS-DRG assignments, aiming to accurately reflect illness severity and resource use.

The role emphasizes concurrent reviews, education of providers, and coordination across HIM, Utilization Review, and Quality Management.

Qualifications

• Education required for RN license in NM or via reciprocal agreement
• Bachelor's Degree and Nationally Accredited Nursing Graduate
• Certified coding/clinical documentation credentials expected

Responsabilités

• REVIEW - identify and record principal and secondary diagnoses, procedures, and assign a working MS-DRG
• CONCURRENT REVIEW - perform initial and ongoing reviews for admissions to track documentation
• PROBLEM SOLVING - interpret clinical data and obtain documentation reflecting severity of illness
• ABSTRACTS - use tools to track Documentation Improvement Program metrics and reports
• COMMUNICATION - obtain/clarify diagnoses and comorbidities with physicians
• COORDINATION - facilitate communication across HIM, Utilization Review, Quality Management, and physician leadership
• PROCESS IMPROVEMENT - develop and implement improvement plans and monitor outcomes
• REPORTS - assist in distributing physician profiling reports
• REPORT ANALYSIS - review documentation for severity of illness and outcomes
• EDUCATION - educate physicians and staff on appropriate documentation and queries
• CONFIDENTIALITY - maintain HIPAA compliance
• OTHER - perform additional duties as assigned
• COMPLIANCE - initiate documentation clarifications to accurately support patient severity and risk of mortality

Formation

RN NM license

Certified Coding Specialist (CCS)

CDIP/CDIS

Description du poste

UNMH is seeking a Clinical Documentation Specialist to review and improve inpatient documentation during patient stays. You will collaborate with physicians and care teams to ensure documentation aligns with diagnoses, procedures, and MS-DRG assignments, aiming to accurately reflect illness severity and resource use.

The role emphasizes concurrent reviews, education of providers, and coordination across HIM, Utilization Review, and Quality Management.