RN – Clinical Documentation and Compliance Specialist
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Job Description
Clinical documentation specialist reviewing inpatient records, diagnoses, and billing requirements. Supporting Presbyterian Healthcare Services, New Mexico's nonprofit hospital and health-plan system.
Responsibilities:
- Perform concurrent reviews of inpatient medical records, including DRG assignments and identification of complications, comorbidities, and co-existing conditions
- Document findings from medical record reviews
- Collaborate with Medical Staff, Nursing Staff, patient caregivers, and HIM Coders to improve chart documentation quality
- Assist physicians with documentation requirements supporting medical necessity for hospital and physician billing
- Interpret clinical information, interventions, lab and test results, and query for supporting documentation
- Communicate with physicians and providers to obtain specific principal diagnoses, comorbidities, and complications
- Solicit clarification of existing medical record documentation supporting patient severity of illness
- Act as an expert clinical resource for the HIM Coding team
- Coordinate with the HIM Coding team on coding guideline requirements
- Provide information and education to physicians and providers regarding documentation requirements
- Maintain and disseminate current legal, regulatory, ICD-10, CPT, HCPCS, APC, CMS, JCAHO, and Nursing Standards of Practice knowledge
Requirements:
- Associates degree in Nursing and 5 years clinical experience in an acute care facility or Bachelors degree with 2 yrs CDI experience required
- Achieve CCDS (Certified Clinical Documentation Specialist) within 3 years employment as Clinical Documentation Specialist (CDS)
- Working knowledge of medical terminology, ICD-10, CPT, HCPCS, DRG, disease processes and related procedures required
- Up to date clinical skills and current working knowledge of pathology and pharmacology impacts on care required
- Experience with database, spreadsheet and word process required
- Detail and results oriented, with the ability to maintain accurate, detailed and organized records essential
- Registered Nurse qualification is required by the role title and nursing degree requirements
- Must be able to work weekday schedule Monday-Friday
Benefits:
- Medical insurance
- Dental insurance
- Vision insurance
- Short-term disability insurance
- Long-term disability insurance
- Group term life insurance
- Optional voluntary benefits
- Employee Wellness rewards program
- Gift cards and more for participating in wellness activities
- Drug-free and tobacco-free employer
- Smoke-free campuses
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