RN – Clinical Documentation and Compliance Specialist

🔥 13 hours ago

🌶️ New Mexico – Remote

🌶️ New Mexico – Remote

💵 $65.5k - $111.6k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

🏥📝 Medical Writer

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Presbyterian Healthcare Services

WebsiteLinkedInAll Job Openings

10,000+ employees

Founded 1908

🏥 Healthcare

🏨 Hospitality

Healthcare • Hospitality

Presbyterian Healthcare Services is a not-for-profit integrated healthcare system based in New Mexico that operates hospitals, urgent care clinics, primary care and specialty medical practices (Presbyterian Medical Group), and offers health insurance plans including Medicare Advantage, Medicaid, employer-offered, and individual/family plans. It provides broad clinical services—primary care, behavioral health, transplant, surgery, cancer care, heart and vascular, neuroscience, infusion, rehabilitation, pediatrics, home healthcare, emergency care, and virtual care—plus patient tools (MyChart, myPRES), financial assistance programs, community health initiatives, and support services. The organization emphasizes community health improvement, access to care, patient privacy/security, and care coordination across its facilities and health plans.

📋 Description

• Assist medical staff providers with documentation in the medical record • Review physician documentation daily and track patient diagnoses and procedures to reflect the level of service provided • Develop, schedule, and prioritize workload to ensure completion of all work • Perform concurrent reviews of inpatient medical records, including DRG assignments and identification of complications, co-morbid conditions, and co-existing conditions • Collaborate with medical staff, nursing staff, and other patient caregivers to improve chart documentation accuracy • Assist physicians with documentation requirements supporting medical necessity for hospital and physician billing • Interpret clinical information, interventions, lab and test results, and query for supporting documentation when necessary • Communicate with physicians and providers to obtain specific principal diagnoses, co-morbidities, and complications • Act as an expert clinical resource for the HIM Coding team • Coordinate with the HIM Coding team on coding guideline requirements • Educate physicians and providers regarding documentation requirements • Maintain and disseminate current legal, regulatory, ICD-10, CPT, HCPCS, APC, CMS, JCAHO, and nursing standards knowledge

🎯 Requirements

• Associates degree in Nursing and 5 years clinical experience in an acute care facility or Bachelors degree with 2 yrs CDI experience required • Achieve CCDS (Certified Clinical Documentation Specialist) within 3 years employment as Clinical Documentation Specialist (CDS) • Working knowledge of medical terminology, ICD-10, CPT, HCPCS, DRG, disease processes and related procedures required • Up to date clinical skills and current working knowledge of pathology and pharmacology impacts on care required • Experience with database, spreadsheet and word process required • Detail and results oriented, with the ability to maintain accurate, detailed and organized records essential • Excellent communication skills • Must be flexible to assist with coverage issues and work collaboratively with reviewers, HIM coders, physicians, and staff

🏖️ Benefits

• Medical insurance • Dental insurance • Vision insurance • Short-term disability insurance • Long-term disability insurance • Group term life insurance • Optional voluntary benefits • Employee Wellness rewards program • Gift cards and more through wellness activities • Drug-free and tobacco-free employer • Smoke-free campuses