Registered Nurse Clinical Documentation Specialist
On-siteKenosha, Wisconsin, United States
Job Summary
Review medical records for defined patients concurrently with care, documenting provisional and potential working DRGs until discharge. Facilitate necessary clinical documentation through verbal and written communication with clinicians to ensure accurate coding of service levels and patient acuity. Evaluate documentation patterns to identify improvements, proactively collect required data, and develop reports to monitor program success. Educate patient care teams on clinical documentation requirements and coding guidelines while collaborating with physicians and coders to achieve precise final coding. Requires RN licensure, 3-5 years of acute care experience, and CCS certification preferred.
Required Qualifications
- Associate Degree in Nursing
- 3 - 5 Years
- Licensure to be eligible to practice as a Registered Nurse
- Ability to read, write, hear, speak, and comprehend the English language
- Strong understanding of pathophysiology, disease processes, and diagnostic testing results
- General understanding of ICD coding conventions and DRG methodology
- Strong MS Word and Excel skills
- Strong organizational, analytical, communication, and interpersonal skills
- Ability to work independently as well as part of a team
Desired Qualifications
- CCS (Certified Coding Specialist) preferred
- Previous acute care clinical experience preferred
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