Clinical Documentation Specialist, RN

This is a fully remote position, open to applicants in United States.

📋 Description

• Enhance the overall quality and thoroughness of clinical documentation.

• Conduct admission and continued-stay evaluations in accordance with CDMP guidelines.

• Facilitate modifications to documentation to accurately represent patient severity and ensure appropriate reimbursement.

• Perform follow-up reviews and confirm that clarifications are documented in patient medical records.

• Collaborate concurrently with physicians during patient stays to secure necessary documentation.

• Refer quality, patient safety, and utilization concerns to CDI leadership, nursing, and case management teams.

• Compose compliant, non-leading clinical documentation queries.

• Monitor documentation against core-measure quality indicators and address any instances of non-compliance.

• Work in partnership with physicians, nurses, case managers, and coding staff.

• Assign working DRGs and maintain DRG worksheets up to discharge.

• Conclude diagnoses in collaboration with attending physicians.

• Educate patient care teams and other stakeholders on documentation, coding, reimbursement, and performance methodologies.

• Ensure medical-necessity documentation for levels of care and refer cases to Utilization Review.

• Analyze DRGs to facilitate appropriate payment recovery.

• Engage in cost-containment and revenue-generation initiatives.

• Propose ideas for reducing costs or increasing revenue.

• Achieve daily review assignments, meet deadlines, and maintain productivity standards.

• Adjust schedules and workloads to align with team performance requirements.

• Assist with special projects and other assigned responsibilities.

⛳️ Requirements

• Must be licensed to practice as an RN in Georgia.

• Associate's Degree required.

• Five (5) years of experience in professional nursing practice.

• Demonstrated proficiency in critical care or medical-surgical nursing.

• Exceptional observation skills, analytical thinking, problem-solving capabilities, and both written and verbal communication skills.

• Knowledge of DRG coding optimization strategies and clinical documentation requirements is beneficial.

• Strong interpersonal skills and professionalism are essential.

• Proficient computer skills with the ability to work independently.

• Familiarity with ICD10 coding conventions, anatomy and physiology, medical terminology, MSDRG reimbursement, and coding software, preferably 3M 360 Encompass.

• Leadership skills are necessary.

• Must adhere to the requirements outlined in the Remote Agreement.

• Preferred: CCDS or CDIP certification.

• Preferred: Bachelor's Degree in Nursing along with additional studies in Finance, Healthcare regulations, and diagnosis-procedure coding.

• Preferred: Experience in Healthcare Utilization and Revenue Management.

🏝️ Benefits

• Opportunity for remote work, sustained through adherence to the Remote Agreement.

• Equal Opportunity Employer.