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Registered Nurse, Clinical Documentation Specialist – CDIP, CCDS
Northeast Georgia Health SystemRegistered Nurse enhancing clinical documentation for Northeast Georgia Health System. Collaborating with healthcare teams to ensure accurate documentation and appropriate reimbursement.
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
clinical documentationDRG codingICD10 codinganatomyphysiologymedical terminologycoding softwareHealthcare UtilizationRevenue Managementcoding optimization strategies
Soft Skills
analytical thinkingproblem-solvingwritten communicationverbal communicationleadershipcollaborationorganizationeducationinteractionmonitoring
Tools & Technologies
Compliant Documentation Program Management (CDMP)core measure quality indicators
Certifications & Qualifications
RN LicensureCCDSCDIP
Industry Keywords
clinical documentation improvementhealthcare regulationsdiagnoses-procedure codingnon-compliance documentationpatient care teamIDT RoundsreimbursementGeorgiaprofessional nursingAssociates Degree
About the role
Key responsibilities & impact- Improving the overall quality and completeness of clinical documentation
- Modifying clinical documentation through interaction with Physicians, Nursing staff, other patient caregivers, and medical records coding staff
- Ensuring appropriate reimbursement is received for services rendered
- Educating all members of the patient care team on clinical documentation
- Conducting admission/continued stay reviews using the Compliant Documentation Program Management (CDMP) guidelines
- Monitoring documentation against "core measure" quality indicators and addressing non-compliance documentation
- Collaborating with coding staff to assign the "working" DRG to contribute for IDT Rounds
- Maintaining a leadership role to ensure compliant documentation
- Organizing and performing work effectively and efficiently
Requirements
What you’ll need- Current RN Licensure in the State of Georgia
- Associates Degree
- Minimum of five (5) years in the practice of professional nursing
- CCDS or CDIP certifications preferred
- Bachelor's Degree in Nursing preferred
- Additional education in Finance, Healthcare regulations, and diagnoses-procedure coding preferred
- Experience in Healthcare Utilization and Revenue Management preferred
- Working knowledge of DRG coding optimization strategies and clinical documentation requirements
- Familiar with ICD10 coding conventions, anatomy and physiology, medical terminology, MSDRG reimbursement, coding software
- Excellent analytical thinking, problem-solving abilities, and written and verbal communication skills
Benefits
Comp & perks- Health insurance
- 401(k) matching
- Paid time off
- Flexible work hours
- Professional development opportunities