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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.
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
ATS Keywords
✓ Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills & Tools
clinical documentationDRG codingICD10 codinganatomyphysiologymedical terminologycoding softwareHealthcare UtilizationRevenue Managementcoding optimization strategies
Soft Skills
analytical thinkingproblem-solvingwritten communicationverbal communicationleadershipcollaborationorganizationeducationinteractionmonitoring
Certifications
RN LicensureCCDSCDIP