Clinical Documentation Registered Nurse RN- Remote $10K Sign On Bonus

Job Summary

Responsible for reviewing medical records to facilitate and obtain appropriate physician documentation for clinical conditions or procedures to support appropriate severity of illness, expected risk of mortality, and complexity of care.

Essential Duties And Responsibilities

• Record Review: Complete initial medical records reviews within 24-48 hours of admission to evaluate documentation for principal diagnosis, secondary diagnoses, and procedures.
• Conduct follow-up reviews every 2-3 days to support and assign working or final MS-DRG upon discharge.
• Formulate physician queries regarding missing, unclear, or conflicting health record documentation.
• Collaborate with case managers, nursing staff, and ancillary staff to resolve physician queries prior to discharge.
• Assist in training department staff new to CDI.
• Stay current with AHA Official Coding and Reporting Guidelines, CMS, and other agency directives.

Knowledge, Skills, and Abilities

• Advanced knowledge of Medicare Part A and familiarity with Medicare Part B.
• Intermediate knowledge of disease pathophysiology and drug utilization.
• Intermediate knowledge of MS-DRG classification and reimbursement structures.
• Critical thinking, problem-solving, and deductive reasoning skills.
• Effective written and verbal communication skills.

Education and Experience

• Graduate from a Nursing program, BSN, or graduate.
• Zero (0) to two (2) years of experience.
• Acute care nursing relevant experience preferred.