Registered Nurse-Clinical Documentation Specialist III-Full Time (Remote)
About the position The Registered Nurse-Clinical Documentation Specialist III is responsible for ensuring the quality and completeness of clinical documentation in medical records. This role involves conducting thorough reviews of medical records to accurately reflect patient conditions, severity of illness, and resource utilization. The specialist serves as a subject matter expert in clinical documentation, collaborating with healthcare providers to enhance documentation practices and ensure appropriate reimbursement for services rendered. Responsibilities • Assess clinical documentation through extensive review of the medical record. • Interact with providers, nursing staff, and coding staff to ensure accurate reimbursement for services. • Conduct post-discharge reconciliation for comparative analysis of CDI specialist and final coding. • Formulate clinical documentation clarifications to improve documentation accuracy. • Query providers and APPs to clarify documentation in the EMR. • Maintain a query rate of at least 20% with an average of 20 reviews per day. • Participate in departmental education and training sessions. • Assist in precepting new CDI nurses and serve as a subject matter expert. • Collaborate with the healthcare team to resolve physician queries prior to discharge. • Analyze clinical information to identify gaps in physician documentation. • Identify ongoing documentation improvement opportunities. • Create and manage review processes and support tools. • Support the Quality department and uphold standards of conduct. • Act as a consultant to coding professionals for additional documentation needs. • Perform patient chart reviews during absences and when coverage is necessary. Requirements • Associates Degree in Nursing (Required) • Bachelors Degree in Nursing or healthcare related field (Preferred) • 5-6 years of Acute Care Nursing experience (Required) • 3-4 years of CDI experience (Required) • 3-4 years of ICD-10-CM & ICD-10-PCS experience (Required) • 1 year of 3M 360 experience (Preferred) • Registered Nurse (RN) license in Virginia (Required) • Certified Documentation Integrity Practitioner (CDIP) or Certified Clinical Document Specialist (CD) (Required) Nice-to-haves • Strong verbal communication skills • Knowledge of basic nursing principles and protocols • Proficient in clinical practice protocols for medical procedures and patient care • Time management and decision-making skills • Excellent organizational skills with attention to detail • Understanding of medical records organization and medical terminology • Ability to establish good customer relationships with trust and respect • Strong clinical assessment and critical thinking skills Benefits • Remote work eligibility for candidates in specified states • Competitive salary range • Opportunities for professional development and education • Supportive work environment with a focus on quality and customer service Apply tot his job