Senior Clinical Documentation Registered Nurse, RN
Tenet Healthcare
Clinical Documentation Registered Nurse, RN
Tenet Healthcare
full-time
Posted on:
Location Type: Hybrid
Location: Alabaster • Alabama • 🇺🇸 United States
Visit company websiteSalary
💰 $72,508 - $108,763 per year
Job Level
Junior
About the role
- Responsible for reviewing medical records to facilitate and obtain appropriate physician documentation for any clinical conditions or procedures
- Completes initial medical records reviews of patient records within 24-48 hours of admission
- Conducts follow-up reviews of patients every 2-3 days
- Formulate physician queries regarding missing, unclear or conflicting health record documentation
- Collaborates with case managers, nursing staff and other ancillary staff regarding interaction with physicians
- Assist in training department staff new to CDI
- Stays current with AHA Official Coding and Reporting Guidelines, CMS and other agency directives for ICD-9-CM and CPT coding
- Communicates/Completes Clinical Documentation Improvement (CDI) activities and coding issues for appropriate follow-up and resolution
- Other duties as assigned
Requirements
- Preferred: Acute Care nursing relevant experience
- Zero (0) to two (2) years experience
- Graduate from a Nursing program, BSN, or graduate
- Active state Registered Nurse license
- Preferred: CDIP or CCDS
Benefits
- Medical, dental, vision, disability, and life insurance
- Paid time off (vacation & sick leave) – min of 12 days per year, accrue at a rate of approximately 1.84 hours per 40 hours worked.
- 401k with up to 6% employer match
- 10 paid holidays per year
- Health savings accounts, healthcare & dependent flexible spending accounts
- Employee Assistance program, Employee discount program
- Voluntary benefits include pet insurance, legal insurance, accident and critical illness insurance, long term care, elder & childcare, AD&D, auto & home insurance.
Applicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard skills
ICD-9-CM codingCPT codingclinical documentation improvement
Soft skills
collaborationcommunicationtraining
Certifications
Registered Nurse licenseCDIPCCDS