Registered Nurse, Clinical Documentation Specialist – CDIP, CCDS
Job Description:
- 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:
- 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:
- Health insurance
- 401(k) matching
- Paid time off
- Flexible work hours
- Professional development opportunities