RN – Clinical Documentation and Compliance Specialist
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Job Description
Clinical Documentation and Compliance Specialist improving inpatient records and coding accuracy. Supporting Presbyterian’s New Mexico hospitals, physicians, and HIM coding teams.
Responsibilities:
- Assist medical staff providers with documentation in the medical record
- Review physician documentation daily and track patient diagnoses and procedures to reflect the level of service provided
- Develop, schedule, and prioritize workload to ensure completion of all work
- Perform concurrent reviews of inpatient medical records, including DRG assignments and identification of complications, co-morbid conditions, and co-existing conditions
- Collaborate with medical staff, nursing staff, and other patient caregivers to improve chart documentation accuracy
- 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 when necessary
- Communicate with physicians and providers to obtain specific principal diagnoses, co-morbidities, and complications
- Act as an expert clinical resource for the HIM Coding team
- Coordinate with the HIM Coding team on coding guideline requirements
- Educate physicians and providers regarding documentation requirements
- Maintain and disseminate current legal, regulatory, ICD-10, CPT, HCPCS, APC, CMS, JCAHO, and nursing standards 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
- Excellent communication skills
- Must be flexible to assist with coverage issues and work collaboratively with reviewers, HIM coders, physicians, and staff
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 through wellness activities
- Drug-free and tobacco-free employer
- Smoke-free campuses
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