Clinical Documentation Registered Nurse improving physician documentation quality for accurate clinical records. Reviewing patient files to support MS-DRG assignment and coordinating with healthcare teams.
Responsibilities
Responsible for reviewing medical records to facilitate and obtain appropriate physician documentation for any clinical conditions or procedures
Completes initial medical records reviews of patient records within 24-48 hours of admission
Conducts follow-up reviews of patients every 2-3 days
Formulate physician queries regarding missing, unclear or conflicting health record documentation
Collaborates with case managers, nursing staff and other ancillary staff regarding interaction with physicians
Assist in training department staff new to CDI
Stays current with AHA Official Coding and Reporting Guidelines, CMS and other agency directives for ICD-9-CM and CPT coding
Communicates/Completes Clinical Documentation Improvement (CDI) activities and coding issues for appropriate follow-up and resolution
Other duties as assigned
Requirements
Preferred: Acute Care nursing relevant experience
Zero (0) to two (2) years experience
Graduate from a Nursing program, BSN, or graduate
Active state Registered Nurse license
Preferred: CDIP or CCDS
Benefits
Medical, dental, vision, disability, and life insurance
Paid time off (vacation & sick leave) – min of 12 days per year, accrue at a rate of approximately 1.84 hours per 40 hours worked.
401k with up to 6% employer match
10 paid holidays per year
Health savings accounts, healthcare & dependent flexible spending accounts
Employee Assistance program, Employee discount program
Voluntary benefits include pet insurance, legal insurance, accident and critical illness insurance, long term care, elder & childcare, AD&D, auto & home insurance.
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