RN Clinical Documentation Specialist
On-siteFargo, North Dakota, United States
Job Summary
Communicate with providers, case managers, and coders to facilitate comprehensive medical record documentation reflecting clinical treatment, decisions, and diagnoses for inpatients and residents. Utilize the hospital's designated clinical documentation system to identify opportunities for physician and hospital outcomes, providing or coordinating education on compliance, coding, and clinical documentation issues. Act as a consultant to coders when additional information or documentation is needed to assign the correct diagnosis-related group (DRG). Evaluate documentation by the medical staff and healthcare team daily, gathering and analyzing information pertinent to documentation findings and outcomes. Perform record reviews on clients in all age groups and coordinate with ancillary and support services to control variances and duplication.
Required Qualifications
- Bachelor's degree in nursing
- Three years of recent clinical nursing experience
- Currently holds an unencumbered RN license with the State Board of Nursing where the practice of nursing is occurring and/or possess multistate licensure if in a Nurse Licensure Compact (NLC) state
- Obtains and subsequently maintains required department specific competencies and certifications
Desired Qualifications
- Graduate from a nationally accredited nursing program, including, but not limited to, Commission on Collegiate Nursing Education (CCNE), Accreditation Commission for Education in Nursing (ACEN), and National League for Nursing Commission for Nursing Education Accreditation (NLN CNEA)
- If no degree, will consider seven years equivalent work experience
- Experience in case management, utilization management, and/or coding
- Certification in Clinical Documentation Specialist (CCDS) or Clinical Documentation Improvement and Integrity (C-CDI)
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