Clinical Documentation Specialist, RN

🔥 0 minutes ago

🇺🇸 United States – Remote

⏰ Full Time

🟡 Mid-level

🟠 Senior

🏥📝 Medical Writer

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Northeast Georgia Health System

WebsiteLinkedInAll Job Openings

10,000+ employees

🏥 Healthcare

⚕️ Healthcare Insurance

Healthcare • Healthcare Insurance

Northeast Georgia Health System is a healthcare organization dedicated to improving the health of the community it serves. With a presence that includes 5 hospitals, 6 urgent care locations, and more than 110 doctor's offices, imaging centers, cancer treatment centers, and laboratories, the system offers a comprehensive range of medical services. It provides career opportunities in various areas, including nursing, allied health, and support services, as well as residencies and fellowships for healthcare professionals. The organization is committed to its mission through adherence to core values, offering employee benefits, and engaging in community activities. With locations providing access to both metropolitan and natural amenities, it emphasizes quality of life for employees and residents in Northeast Georgia.

📋 Description

• Improve the overall quality and completeness of clinical documentation • Perform admission and continued-stay reviews using CDMP guidelines • Facilitate documentation modifications to accurately reflect patient severity and support appropriate reimbursement • Conduct follow-up reviews and ensure clarifications are recorded in patient medical records • Work concurrently with physicians during patient stays to obtain required documentation • Refer quality, patient safety, and utilization concerns to CDI leadership, nursing, and case management • Write compliant, non-leading clinical documentation queries • Monitor documentation against core-measure quality indicators and address non-compliance • Collaborate with physicians, nurses, case managers, and coding staff • Assign working DRGs and update DRG worksheets through discharge • Finalize diagnoses with attending physicians • Educate patient-care teams and other audiences on documentation, coding, reimbursement, and performance methodologies • Ensure medical-necessity documentation for levels of care and refer cases to Utilization Review • Analyze DRGs to support appropriate payment recovery • Participate in cost-containment and revenue-generation efforts • Submit ideas for reducing cost or adding revenue • Meet daily review assignments, deadlines, and productivity standards • Adjust schedules and workloads to meet team performance needs • Assist with special projects and other assigned duties

🎯 Requirements

• Licensed to practice as an RN in Georgia • Associate's Degree • Five (5) years in the practice of professional nursing • Demonstrates aptitude in critical care or medical-surgical nursing • Excellent observation skills, analytical thinking, problem-solving abilities, and written and verbal communication • Working knowledge of DRG coding optimization strategies and clinical documentation requirements helpful • Interpersonal skills and professionalism • Computer skills and ability to be self-directed • Familiarity with ICD10 coding conventions, anatomy and physiology, medical terminology, MSDRG reimbursement, and coding software, preferably 3M 360 Encompass • Leadership skills required • Maintains requirements contained in Remote Agreement • Preferred: CCDS or CDIP certification • Preferred: Bachelor's Degree in Nursing and additional education in Finance, Healthcare regulations, and diagnoses-procedure coding • Preferred: Experience in Healthcare Utilization and Revenue Management

🏖️ Benefits

• Remote work opportunity maintained through compliance with the Remote Agreement • Equal Opportunity Employer