Registered Nurse (RN) Clinical Documentation Specialist (M-F 8-5)

UMC Health System•Richmond, KY

7d•Hybrid

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
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
Critical thinking
Strong clinical skills
Excellent written and verbal communication
Knowledge of Medicare reimbursement procedures and rules
Fundamental knowledge of coding practices

Responsibilities

Concurrent review of the clinical content in the active patient medical record
Query the medical staff to obtain specific and complete documentation that supports the severity of patient illness and risk of mortality
Conduct initial and extended stay reviews on all selected admissions
Identify 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
Relate effectively with other shifts/departments for optimal continuity of care