RN – Clinical Documentation and Compliance Specialist

🔥 16 hours ago

🌶️ New Mexico – Remote

🌶️ New Mexico – Remote

💵 $65.5k - $111.6k / year

⏰ Full Time

🟢 Junior

🟡 Mid-level

🏥📝 Medical Writer

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Presbyterian Healthcare Services

WebsiteLinkedInAll Job Openings

10,000+ employees

Founded 1908

🏥 Healthcare

⚕️ Healthcare Insurance

🤝 Non-profit

Healthcare • Healthcare Insurance • Non-profit

Presbyterian Healthcare Services is an integrated, nonprofit healthcare system based in New Mexico that operates hospitals, urgent care clinics, specialty and primary care practices, virtual care (VirtualPRES), and health insurance plans. The organization provides a broad range of clinical services—including neuroscience, transplant, cancer care, surgery, behavioral health, and home health—while also running community health and charitable programs (financial assistance, community support, and partnerships with medical education). It offers individual, Medicaid, Medicare Advantage, and employer health plans, plus patient tools (MyChart/myPRES), billing support, and commitment to access and quality across the state.

📋 Description

• Perform concurrent reviews of inpatient medical records, including DRG assignments and identification of complications, comorbidities, and co-existing conditions • Document findings from medical record reviews • Collaborate with Medical Staff, Nursing Staff, patient caregivers, and HIM Coders to improve chart documentation quality • 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 • Communicate with physicians and providers to obtain specific principal diagnoses, comorbidities, and complications • Solicit clarification of existing medical record documentation supporting patient severity of illness • Act as an expert clinical resource for the HIM Coding team • Coordinate with the HIM Coding team on coding guideline requirements • Provide information and education to physicians and providers regarding documentation requirements • Maintain and disseminate current legal, regulatory, ICD-10, CPT, HCPCS, APC, CMS, JCAHO, and Nursing Standards of Practice 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 • Registered Nurse qualification is required by the role title and nursing degree requirements • Must be able to work weekday schedule Monday-Friday

🏖️ 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 for participating in wellness activities • Drug-free and tobacco-free employer • Smoke-free campuses