Registered Nurse, Clinical Documentation Specialist

This is a fully remote position, open to applicants in New Hampshire.

📋 Description

• Facilitate enhancements in the quality, completeness, and accuracy of medical record documentation.

• Educate patient care teams, Medical Staff, Hospital Staff, and Coding team members regarding documentation guidelines and clinical updates.

• Conduct ongoing and follow-up reviews of medical records utilizing documentation improvement guidelines.

• Assess the quality and completeness of clinical documentation.

• Interact concurrently with physicians and mid-level providers to gather more detailed medical record information.

• Ensure that the severity of illness and level of services are accurately represented in the medical records.

• Review patients’ clinical profiles and assign working DRGs.

• Input working DRGs into the designated database/IDX system and monitor the completion of DRG worksheets.

• Track and analyze outcomes related to documentation improvement; prepare and present regular progress reports.

• Facilitate and participate in team meetings with Coding staff.

• Collaborate with inpatient coders to ensure accuracy in DRG assignment and reimbursement.

• Develop training programs and performance improvement initiatives focused on clinical documentation enhancement.

• Provide updates in response to regulatory changes.

• Address inquiries from payors regarding clinical denials.

• Offer clinical documentation expertise for outpatient physician documentation issues.

• Undertake other assigned responsibilities.

⛳️ Requirements

• Licensed Registered Nurse with eligibility in NH.

• Minimum of 3 years of relevant experience.

• Ability to forge and sustain strong relationships while confidently discussing clinical diagnoses.

• Excellent verbal and written communication skills.

• Proven interpersonal abilities, including negotiation, conflict resolution, follow-through, and follow-up.

• Strong organizational skills, encompassing project management, attention to detail, and accuracy.

• Capability to design and deliver educational programs on clinical documentation improvement.

• Proficiency in data entry and analysis, word processing, and presentation software.

• Up-to-date clinical knowledge along with the ability to comprehend the clinical aspects of patient conditions and identify opportunities for improved documentation.

• Preferred knowledge of DRG prospective payment systems, documentation and coding guidelines, and compliance requirements.

• Current awareness of DRGs and payment regulations is preferred.

• Prior experience specific to CDI is preferred.

🏝️ Benefits

• Loan repayment assistance up to $20,000.

• Generous tuition reimbursement program.

• Popular "earned time" plan.

• Extensive continuing education and training programs.

• Shared governance nursing model.

• A rigorous, research-focused environment.

• Continuing nursing education offered through an ANCC-accredited provider.

• Equal opportunity employment.