What are the responsibilities and job description for the RN Clinical Documentation Specialist position at Careerbuilder-US?
Title : RN Clinical Documentation Specialist
Duration : 6 Months Contract (Possible Extension)
Location : Milwaukee, WI 53226 – 100% Remote
Remote
o 8hr days – CST first shift
Top qualifications this person will need : o CCDS or CDIP o Risk adjustment CDI - Vizient
Duties : Job Summary :
The Clinical Documentation Specialist is an experienced Clinical Documentation Nurse who has obtained knowledge and expertise in all patient populations across the enterprise to provide comprehensive Clinical Documentation Integrity (CDI) chart reviews. Facilitates modifications to clinical documentation to ensure appropriate reimbursement is received for the level of service rendered. Ensures the accuracy and completeness of clinical information used for measuring and reporting clinical and quality outcomes.
Job Responsibilities :
- Collects and assesses data within CDI software systems.
- Independently applies experience and critical thinking skills to identify opportunities for documentation improvement that support the program and organizational goals.
- Facilitates modifications to clinical documentation to ensure appropriate reimbursement is received for the level of service rendered. Improves quality and completeness of clinical documentation by performing initial, follow-up, reconciliation reviews while adhering to organizational workflows and ACDIS / AHIMA guidelines.
- Provides training and guidance to Associate CDS nurses.
- Identifies and reviews complex clinical issues / service line trends upon reconciliation process via level process with coding. Facilitates and enhances procedural coding practices. Collaborates with physicians, midlevel providers, nursing staff, other patient providers, and coding staff to ensure appropriate reimbursement is received for the level of service rendered and to capture Quality specific codes related to patient encounter specific DRG’s.
- Ensure points of clarification have been recorded in the patient’s chart.
- Maintains records that support appropriate financial reimbursement (DRG and CMI) and organization quality benefit rankings. Other duties as assigned.
