Senior Clinical Documentation Registered Nurse, RN
Tenet Healthcare
full-time
Posted on:
Location Type: Hybrid
Location: Birmingham • Alabama • 🇺🇸 United States
Visit company websiteJob Level
Senior
About the role
- Responsible for reviewing medical records to facilitate and obtain appropriate physician documentation
- Educates members of the patient care team regarding documentation guidelines
- 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
- Communicates/Completes Clinical Documentation Improvement (CDI) activities and coding issues
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
- Competitive benefits package
- Professional development support
Applicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard skills
medical records reviewdocumentation guidelinesclinical documentation improvementphysician queriescoding issues
Soft skills
communicationcollaborationtrainingeducation
Certifications
Registered Nurse licenseCDIPCCDS