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ICU Clinical Documentation Registered Nurse, RN
Tenet HealthcareICU Clinical Documentation Registered Nurse responsible for improving physician documentation quality. Hybrid role focusing on medical record review and collaboration with healthcare teams.
About the role
Key responsibilities & impact- 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
- Evaluates documentation to assign the principal diagnosis, pertinent secondary diagnoses, and procedures for accurate MS-DRG assignment, risk of mortality and severity of illness
- Formulates physician queries regarding missing, unclear, or conflicting health record documentation
- Collaborates with providers, case managers, nursing staff and ancillary staff regarding documentation
- Communicates/Completes Clinical Documentation Integrity (CDI) activities and coding issues
- Assists with Provider education, rounding and communication regarding open queries for resolution
- Stays current with AHA Official Coding and Reporting Guidelines, CMS and other agency directives for ICD10-CM and PCS coding
- Assists in training department staff new to CDI
- Performs other duties as assigned.
Requirements
What you’ll need- Preferred: Acute Care nursing and/or Provider relevant experience
- Zero (0) to two (2) years CDI experience
- Two (2) plus years’ nursing experience – Medical/Surgical/Intensive Care and/or Case/Utilization Review
- Two (2) plus years’ Provider experience – Medical/Surgical/Intensive Care and/or Case/Utilization Review
- Graduate from a Nursing program, BSN, or graduate program; OR
- Graduate from Medical Doctor and/or Foreign Medical Doctor Program
- Active state Registered Nurse license; OR
- Graduate MD and/or FMD license
- Preferred: CDIP or CCDS
Benefits
Comp & perks- Conifer requires its candidates, as applicable and as permitted by law, to obtain and provide confirmation of all required vaccinations and screenings prior to the start of employment. This may include, but is not limited to, the COVID-19 vaccination, influenza vaccination, and/or any future required vaccines and screenings.
ATS Keywords
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Hard Skills & Tools
clinical documentation integrityICD10-CM codingICD10-PCS codingmedical record reviewdiagnosis assignmentMS-DRG assignmentrisk of mortality assessmentseverity of illness assessmentprovider educationquery formulation
Soft Skills
collaborationcommunicationevaluationtrainingproblem-solvingattention to detailinterpersonal skillsorganizational skillscritical thinkingadaptability
Certifications
CDIPCCDSRegistered Nurse licenseBSNMedical Doctor degreeForeign Medical Doctor degree