About the role
- Responsible for concurrent review of inpatient medical records
- Identify opportunities for improving the quality of physician documentation
- Modifications to clinical documentation through interaction with physicians and other healthcare team members
- Achieve a complete medical record to support accurate coding
- Communicate with physicians, case managers, coders, and healthcare team members
- Contribute to a positive working environment
- Coach physicians on improving documentation quality
Requirements
- RN candidate with Clinical Documentation experience
- RN with a BSN or MSN
- At least 5 years of recent RN bedside experience
- Critical care, neuro, trauma or heart & vascular nursing experience preferred
- Current State of Texas license or temporary/compact license to practice professional nursing
- Excellent observation skills, analytical thinking, and problem-solving abilities
- Proficiency in organization, planning, computer usage, and adaptability
- Working knowledge of adult medicine and federal, state, and private payer regulations preferred
- Exceptional experiences for every member of our community
- Professional growth and development opportunities
- Collaborative work environment
Applicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard skills
clinical documentationcodingnursingcritical care nursingneuro nursingtrauma nursingheart & vascular nursingobservation skillsanalytical thinkingproblem-solving
Soft skills
communicationcoachingorganizationplanningadaptabilityteam collaborationpositive working environment
Certifications
RN licenseBSNMSNState of Texas licensetemporary/compact license