FULLY REMOTE 5x8HR DAY SHIFT
- Acute care nursing experience is required.
Position: Clinical Documentation Specialist (RN)
Shift: 5x8HR DAYS (8:00-16:30) – this will be fully remote and not patient facing
Length: 13 weeks
Time Off: Please include all RTO at apply
Requirements: AS of Nursing required, BLS of Nursing or healthcare is preferred. Active WA or Compact RN license Required.
Required Experience: Experience as an RN in acute care setting within the last 5 years AND 2-3 years Clinical Documentation Integrity experience in acute care setting. Preferred: hospital experience in ICU, ED or Medical/Surgical. Understanding of MS-DRG and APR-DRG assignment and fundamentals of establishing a DRG. ICD-10 experience and/or understanding.
Responsibilities: The Clinical Documentation Specialist (CDS) is responsible for supporting and facilitating the overall quality of medical record documentation by improving the completeness, accuracy, and reliability of clinical documentation. A key success factor of this process is educating providers through the query process and independently supporting them with education and feedback to accurately reflect the patient's true clinical picture within the medical record. In partnering with the coding team, the CDS will be an expert with ICD-10, NS-DRG and APR-DRG assignment.
The CDS's primary responsibility will be to obtain appropriate clinical documentation through extensive review of provider, nursing, ancillary, and other patient caregivers' documentation, to ensure that appropriate documentation and reimbursement is received for the level of services rendered to patients. The CDS exercises their judgment and discretion to ensure the clinical information utilized in analyzing and reporting outcomes is complete and accurate. On an ongoing basis, the CDS is responsible for supporting the direction and focus of education for providers and the coding staff within their assigned scope of work. The CDS must exercise independent judgment, critical thinking, ability to work independently while interpreting and following CMS guidelines, organizational policies, and procedures.
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