Registered Nurse, Clinical Documentation Specialist

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🔥 3 minutes ago

🗻 New Hampshire – Remote

🗻 New Hampshire – Remote

⏰ Full Time

🟡 Mid-level

🟠 Senior

🏥📝 Medical Writer

👻 Ghost score 25%

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Dartmouth-Hitchcock Keene

WebsiteLinkedInAll Job Openings

2 - 10 employees

🏥 Healthcare

📚 Education

Healthcare • Education

Dartmouth-Hitchcock Keene is a community hospital and clinical site within the Dartmouth Health system serving Keene, New Hampshire and surrounding communities. It provides inpatient and outpatient medical services, access to specialty clinics, and supportive patient services. As part of Dartmouth Health, the Keene facility is linked to system-wide research and clinical trials, education for residents and fellows, community outreach, population health initiatives, and volunteer/donor programs.

📋 Description

• Facilitate improvement in the quality, completeness, and accuracy of medical record documentation • Educate patient care teams, Medical Staff, Hospital Staff, and Coding team members on documentation guidelines and clinical updates • Perform ongoing and follow-up medical record reviews using documentation improvement guidelines • Evaluate the quality and completeness of clinical documentation • Interact concurrently with physicians and mid-level providers to obtain more detailed medical-record information • Ensure severity of illness and level of services are accurately reflected in the medical record • Review patients’ clinical pictures and assign working DRGs • Enter working DRGs into the appropriate database/IDX system and track DRG worksheet completion • Track and analyze documentation improvement outcomes; prepare and present regular progress reports • Facilitate and participate in team meetings with Coding staff • Collaborate with inpatient coders on DRG assignment and reimbursement accuracy • Develop clinical documentation improvement training and performance-improvement programs • Provide updates as regulations change • Respond to payors concerning clinical denials • Provide clinical documentation expertise for outpatient physician-documentation issues • Perform other assigned duties

🎯 Requirements

• Licensed Registered Nurse with NH eligibility • 3 years of applicable experience • Ability to create and maintain strong relationships and confidently discuss clinical diagnoses • Excellent verbal and written communication abilities • Demonstrated interpersonal skills, including negotiation, conflict resolution, follow-through and follow-up • Good organizational skills, including project management, attention to detail and accuracy • Ability to develop and deliver clinical education programs on clinical documentation improvement • Computer competencies in data entry and analysis, word processing, and presentations • Up-to-date clinical knowledge and ability to understand the clinical picture of patient conditions and identify opportunities for improved documentation • Knowledge of DRG prospective payment systems, documentation and coding guidelines, and compliance requirements preferred • Current knowledge of DRGs and payment regulations preferred • CDI-specific experience preferred

🏖️ Benefits

• Loan repayment up to $20,000 • Generous tuition reimbursement • Popular "earned time" plan • Extensive CEU/Training programs • Shared governance nursing model • Rigorous, research-focused environment • Continuing nursing education through an ANCC-accredited provider • Equal opportunity employment