RN Clinical Documentation Specialist

Cone Health, United StatesRemoteFull-time3+ yrs experiencePosted 2w ago

Job description

Registered Nurses Mon-Fri

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The RN Clinical Documentation Specialist is a clinical position using clinical/nursing knowledge of documentation requirements to improve overall quality and completeness of documentation in the patient’s medical record using a multidisciplinary team approach. Works in collaborative effort with providers to ensure clinical information in the medical record is present and accurate, capturing the appropriate severity of illness and risk of mortality for the level of services provided and the appropriate DRG.

Essential Job Function:

Initiates and performs documentation review (initial & follow up) of selected records to clarify conditions/diagnoses & procedures where inadequate or conflicting documentation exists in accordance with department standards.
Ensures correct MS-DRG assignment, Severity of Illness (SOI)/risk of Mortality (ROM) scoring & identification of Hospital Acquired Conditions.
Performs appropriate query process.
Supports planning and educational processes of the Clinical Documentation Improvement Program.
Develops and maintains effective working relationships with colleagues and communicates effectively with multidisciplinary teams.
Meet established departmental goals/standards.
Performs other duties as assigned.

Education:

Required: Bachelor's Degree in Nursing.

Experience:

Required: 3 years.

Licensure/Certification/Listing:

Required: Registered Nurse licensed in NC or compact State Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Practitioner (CDIP), If not certified, CCDS or CDIP must be completed within 1 year after eligibility period met.

Work Shift :

Days/No Weekends (United States of America)

On Call Required

FTE:

Job Type:

Full Time (40 Hours/Week)

Job details are sourced from the employer's original posting.

Open job posting

About the company

Cone Health

Recognized for Excellence in Neurology Moses H. Cone Memorial Hospital ranks in the top 10 percent of the nation for medical excellence in neurological care, according to CareChex . That means you can trust us to provide advanced inpatient services, protect patient safety, and offer care with lower-than-average rates of complications. Cone Health has been named a Blue Distinction Center+ for Spine Surgery by Blue Cross and Blue Shield of North Carolina (BCBSNC). Hospitals with this designation demonstrate expertise in cervical and lumbar fusion, cervical laminectomy and lumbar laminectomy/discectomy procedures, resulting in fewer patient complications and hospital readmissions compared to other hospitals. Our outstanding services include stroke care at Moses Cone Hospital and other Cone Health facilities, which have earned numerous recognitions for helping stroke patients achieve better-than-average outcomes.

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Industry: Healthcare
Open roles: 702