RN Clinical Documentation Specialist
Ensemble Health Partners
full-time
Posted on:
Location Type: Hybrid
Location: Winchester • Virginia • United States
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Salary
💰 $80,000 per year
About the role
- Facilitates and obtains appropriate physician documentation for any patient clinical condition or procedure
- Completes timely initial and concurrent reviews of the patient medical record for Diagnosis Related Group (DRG) and documentation integrity utilizing CDI Software
- Assigns working Principal diagnosis, complication and comorbidity/major complication and comorbidity (CC/MCC)
- Clarifies with providers regarding missing, unclear, unsupported or conflicting medical record documentation per regulatory guidelines
- Educates healthcare providers regarding clinical documentation improvement and documentation guidelines
- Partners with coding professionals to ensure accuracy of documentation
Requirements
- Minimum of five years acute care nursing experience with specific medical/surgical, Intensive Care, or Emergency Department experience
- Excellent interpersonal skills including verbal and written communication skills
- Ability to conduct brief presentations to a variety of audiences in clinical space
- Flexibility in assignments and workloads based on team needs
- Ability to organize and present information clearly and concisely
- Excellent computer and keyboarding skills
- High degree of prioritization skills
- Licensed Registered Nurse
- Licensed Medical Doctor
- Nurse Practitioner
- Physician Assistant
- CCDS (Certified Clinical Documentation Specialist) certification
- CDIP (Certified Documentation Improvement Practitioner (CDIP))
- CRCR (Certified Revenue Cycle Representative), required within 9 months of hire
Benefits
- Bonus Incentives
- Paid Certifications
- Tuition Reimbursement
- Comprehensive Benefits
- Career Advancement