Clinical Documentation Specialist-RN
About The Position
As a Clinical Documentation Specialist RN, you will be responsible for facilitating accurate documentation for severity of illness and quality in the medical record. This involves extensive record review, interaction with physicians, health information management professionals, and nursing staff. Active participation in team meetings and education of staff in the CDMP process is a key role. Every day, you will leverage your expertise to provide individualized, comprehensive care, making critical assessments, performing skilled procedures, and meticulously implementing patient care plans. You'll collaborate seamlessly within an interdisciplinary team, contributing to a dynamic environment focused on optimal patient outcomes.
Requirements
- Current Registered Nurse (RN) license that allows you to practice in our state
- Graduate of an accredited nursing program
- Five (5) years of adult acute care experience in med/surg, critical care, emergency room, or PACU
- High school diploma or GED
Nice To Haves
- Responsible and compassionate Registered Nurse with top-notch clinical skills
- Caring attitude
- Ability to work independently with minimal supervision
- Excellent verbal and written communication and interpersonal skills
- Ability to effectively educate patients and their families on the in-home healthcare process
Responsibilities
- Reviews medical record for completeness and accuracy for severity of illness (SOI) and quality using the Compliant Documentation Management Program (CDMP) documentation strategies
- Accurate and timely record review
- Recognize opportunities for documentation improvement
- Formulate clinically credible documentation clarifications
- Request documentation clarifications as appropriate for SOI, Core Measures, and Patient Safety
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What This Job Offers
Job Type
Full-time
Career Level
Senior
Education Level
High school or GED
