Registered Nurse (RN) Clinical Documentation Specialist (M-F 8-5)
About The Position
The Clinical Documentation Specialist (CDS) provides concurrent review of the clinical content in the active patient medical record and queries the medical staff to obtain specific and complete documentation that supports the severity of patient illness and risk of mortality. The CDS conducts initial and extended stay reviews on all selected admissions and identifies opportunities for improvement, education, and increased. Registered professional nurse who assesses, implements or delegates, plans, and evaluates total nursing care and functions in accordance with established philosophy. Relates effectively with other shifts/departments for optimal continuity of care.
Requirements
- Graduation from an accredited School of Nursing
- Valid Texas RN License/Eligible Compact License
- Must maintain a current BLS certification from American Heart Association
- Minimum of 5 years of acute care experience.
- CDI Certification required within 2 years of eligibility.
- BSN required or must be obtained within 3 years of hire
Nice To Haves
- Critical thinking
- Strong clinical skills
- Excellent written and verbal communication
- Knowledge of Medicare reimbursement procedures and rules
- Fundamental knowledge of coding practices
Responsibilities
- Provides concurrent review of the clinical content in the active patient medical record.
- Queries the medical staff to obtain specific and complete documentation that supports the severity of patient illness and risk of mortality.
- Conducts initial and extended stay reviews on all selected admissions.
- Identifies opportunities for improvement, education, and increased.
- Assesses, implements or delegates, plans, and evaluates total nursing care and functions in accordance with established philosophy.
- Relates effectively with other shifts/departments for optimal continuity of care.
Stand Out From the Crowd
Upload your resume and get instant feedback on how well it matches this job.
What This Job Offers
Job Type
Full-time
Career Level
Senior
