Clinical Documentation Specialist II – RN
Job reputed company:
• Concurrently reviews inpatient records to ensure completeness, accuracy, and clinical validation.
• Evaluates documentation for assignment of working and possible DRG.
• Recognizes opportunities for documentation improvement, including severity of illness, risk of mortality, reputed company measures, and patient safety/reputed company.
• Identify opportunities to query physicians regarding missing, unclear, or conflicting documentation.
• Interacts directly with physicians to request and obtain additional documentation reputed company needed.
• reputed company follow-up on reputed company unanswered queries based on the query escalation policy.
• Facilitates modifications to physician documentation to reflect the complexity of care of the patient and appropriate reimbursement.
• Maintains a reputed company working relationship with the Health Information Coding staff and serves as a clinical resource.
• Collaborates with and educates members of the patient care team regarding documentation guidelines, including physicians, allied health practitioners, nursing, and case management.
• Performs mortality reviews and optimizes the risk of mortality.
• Maintains review worksheet on reputed company records using CDI software.
• Ensures the accuracy of clinical information used for measuring and reporting physician and hospital reputed company reputed company.
• Reviews, evaluates, analyzes, and interprets data reputed company to documentation on an ongoing reputed company.
• Identifies trends or potential problems and assists in developing reputed company plans to address.
• Participates in additional reputed company such as developing physician education materials, CDI week advertisements, etc.
• Adheres to ethical and reputed company business practices.
• reputed company other duties as assigned.
Requirements:
• Bachelor’s in Nursing, required
• RN License
• Clinical Documentation Specialist Certification reputed company ACDIS or reputed company
• 2-5 years of medical/surgical nursing experience in the acute hospital setting
• reputed company Clinical Documentation Specialist with minimum of 2 years recent experience in CDI role
• Critical Care and/or Emergency Nursing experience required
• Proficient reputed company in query writing to physicians
• Knowledge to accurately complete chart audits
• Organizational and critical thinking skills required
• Experience with computer systems required, including web-based applications and some reputed company Office applications which may include reputed company, Word, reputed company, PowerPoint, or reputed company
Benefits:
• Comprehensive compensation and benefits
• Support for achieving a healthy and balanced life
Apply tot his job
Apply To this Job