Registered Nurse
1 month ago
Sign-on Bonus and Relocation Reimbursement available
Receive 17% weekday nights, 26% weekend nights, or 15% weekend day shift differentials
Department: HIM Clinical Documentation
FTE: 1.00
Full Time
Shift: Days
Position Summary:
Responsible for concurrent review of appropriate and complete clinical documentation in the electronic medical record to support services ordered and/or received, support primary diagnosis, secondary diagnoses, and co-morbidities to improved medical record physician documentation to appropriately support the severity of patient illness and resource consumption. Utilization of abstracting and data entry software tools to perform coding, abstracting and reporting functions. Provide training for caregivers in appropriate clinical documentation as indicated. Indirectly assures case mix index, DRG assignment and severity/mortality profiles are accurate. Ensure adherence to Hospitals and departmental policies and procedures. No patient care assignment.
Detailed responsibilities:
* REVIEW - In collaboration with the physician, nurse, patient care coordinator, and certified coding specialist (CCS), identify and record principle diagnoses, secondary diagnoses, procedures, and assign a working MS-DRG. Present results as individual teaching case reviews to the attending physician(s) and/or department or division members
* CONCURRENT REVIEW - Conduct initial concurrent review and ongoing re-reviews for all selected admissions to initiate the tracking process, document findings on the MS-DRG worksheets, and identify other key quality indicators as appropriate
* COMPLIANCE - Identify the need to clarify documentation in medical records and initiate communication with physician, nurse, or patient care coordinator by utilizing the appropriate “query” tools in order to capture the documentation in the medical record that accurately supports the patient’s severity of illness
* PROBLEM-SOLVING - Interpret clinical information in the medical record, evaluate medications, vital signs, surgical outcomes, etc. Identify potential diagnoses based on this information and communicate with physicians to obtain appropriate documentation that most accurately reflects patient severity, risk of mortality, length of stay. Train providers in the art of appropriate diagnosis descriptions to capture the abnormal signs and symptoms treated for all complications and co-morbidities for each patient as part of their normal documentation
* ABSTRACTS - Utilize monitoring tools to track the progress of the Documentation Improvement Program and identified quality indicator tracking elements, interpret tracking information and reports findings to the Health Information Management, Quality Management, and Utilization Review/Case Management meetings as requested. Identify department and/or specialty trends and patterns that show opportunities for improvements in documentations
* PHYSICIAN COMMUNICATION – Participate in clinical rounding and other communication with physicians and residents on the inpatient units to obtain/clarify specific principal diagnoses or comorbidities and complications that pertain to the clinical information shared on specific patients during rounding; assist the rounding team with clarification of appropriate documentation that identifies diagnoses vs. ill-defined clinical symptoms; facilitate assertive, tactful communication when encountering resistance due to perception that information is adequately documented to achieve complete documentation per coding guidelines
* COORDINATION - Coordinate and facilitate communication between Health Information Management, Utilization Review/Case management, Quality Management, physician leadership to acquire, interpret, and transmit accurate diagnostic and procedure documentation. Establish good working relationships with department Chairs and department Administrators to improve documentation
* PROCESS IMPROVEMENT - Analyze baseline outcomes; develop process improvement plans to improve baseline to a higher level of performance; prioritize and implement process improvement action plans; monitor results, and present results in a way to capture provider interest and motivate change in documentation practices
* REPORTS - Assist in the communication and distribution of physician profiling reports provided in conjunction with the Clinical Documentation Improvement Program software. Prepare Department and/or Division metrics reports for monthly meetings for areas assigned
* REPORT ANALYSIS – Create appropriate reports to demonstrate improvements in major complication and comorbidity (MCC) and/or complication and comorbidity (CC) capture rates. Use report analysis to demonstrate missed opportunities to appropriate capture the true severity of illness patients
* EDUCATION - Use query statistics and query type information to create training materials for physicians and ancillary staff. Identify opportunities for physician education to improve medical record documentation for severity of illness on an ongoing basis. Identify opportunities for coder education to improve coder query opportunities for MCCs and CCs
* LEADERSHIP - Demonstrate strong clinical documentation leadership skills to become a valuable CDI specialist for medical departments and divisions assigned
* CONFIDENTIALITY - Maintain confidentiality of patient records, adhering to HIPAA guidelines
Related Education and Experience may be substituted for one another on a year for year basis.
Education:
Essential:
* Master's Degree
Education specialization:
Essential:
* MSN or Related Discipline w/certification in HIM/HIT
Experience:
Essential:
3 years directly related experience
Nonessential:
No preferred experience
Credentials:
Essential:
* RN in NM or as allowed by reciprocal agreement by NM
* Certified Document Improvement Practitioner
Nonessential:
* Certified Coding Specialist
Physical Conditions:
Sedentary Work: Exerting up to 10 pounds of force occasionally (Occasionally: activity or condition exists up to 1/3 of the time) and/or a negligible amount of force frequently (Frequently: activity or condition exists from 1/3 to 2/3 of the time) to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and all other sedentary criteria are met.
Working conditions:
Essential:
* Minor Hazard - physical risks, dirt, dust, fumes, noise
Department: Registered Nurse
-
Registered Nurse
4 weeks ago
Albuquerque, United States Critical Nurse Staffing, LLC Full timeJob Type Full-time, Part-time Description Registered Nurse - RNPrivate duty caregiver Full-Time / part-TimeBenefits at 30+ hrs./week|$35.00-$45.00 | Come work for CNS Cares, LLC. (CNS) and make a difference! As a direct care professional in home healthcare, you will get the opportunity to provide compassionate care to individuals in their home and give back...
-
Registered Nurse
2 days ago
Albuquerque, United States Critical Nurse Staffing, LLC Full timeJob Type Full-time, Part-time Description Registered Nurse - RNPrivate duty caregiver Full-Time / part-TimeBenefits at 30+ hrs./week|$35.00-$45.00 | Come work for CNS Cares, LLC. (CNS) and make a difference! As a direct care professional in home healthcare, you will get the opportunity to provide compassionate care to individuals in their home and give back...
-
Registered Nurse
4 weeks ago
Albuquerque, United States Jackson Nurse Professionals Full timeA challenging but rewarding position is open for a Registered Nurse with experience caring for patients undergoing life-threatening trauma or illnesses for a 13 week contract assignment at a state-of-the-art hospital. You'll experience an incredibly supportive and ambitious team at Jackson where Traveling Nurses have been building rewarding careers since...
-
Travel Registered Respiratory Therapist
1 day ago
Albuquerque, United States Nurse First Full timeJob DescriptionNurse First is seeking a travel Registered Respiratory Therapist for a travel job in Albuquerque, New Mexico.Job Description & RequirementsSpecialty: Registered Respiratory TherapistDiscipline: Allied Health ProfessionalStart Date: 08/05/2024Duration: 26 weeks36 hours per weekShift: 12 hours, flexibleEmployment Type: TravelNurse First Job ID...
-
Registered Nurse
4 weeks ago
Albuquerque, United States NR Consulting Full timeJob Title: Registered Nurse Work Location: 5900 Forest HIlls Dr. NE, Albuquerque, NM, 87109 Position Type: Contract with Possible Extension Duration: 3+ Months Registered Nurse Responsibilities: Maintaining accurate, complete health care records and reports. Administering medications to patients and monitoring them for side effects and reactions....
-
Registered Nurse
7 days ago
Albuquerque, United States Santa Fe Recovery Center Full timeCompany Description Santa Fe Recovery Center is dedicated to helping individuals sustain lasting recovery from substance use disorders and related mental health disorders. We provide culturally relevant, evidence-based treatment and education in partnership with other community organizations. Our team is committed to making a positive impact in the lives of...
-
Registered Nurse
2 weeks ago
Albuquerque, New Mexico, United States Veterans Health Administration Full timePsychiatric/Mental Health Registered Nurse Position at New Mexico VA Health Care SystemSummaryInpatient positions at the New Mexico VA Health Care System are eligible for the Education Debt Reduction Program (EDRP), a student loan payment reimbursement program. If hired, you must meet specific individual eligibility requirements and submit your EDRP...
-
Registered Nurse
4 weeks ago
Albuquerque, New Mexico, United States CareerStaff Unlimited Full timeRegistered Nurse - RN - LTAC Featuring an emphasis on personalized care, this hospital located in York, PA, is an ideal location to grow a career in long-term acute care. Enjoy a supportive team of highly-motivated caregivers to help you provide care for hospital patients and exceed in long-term acute care. PAY: $2,000/Weekly Gross 36 hours/Week ABOUT...
-
Skilled Nursing Registered Nurse
3 weeks ago
Albuquerque, United States Supplemental Health Care Full timeJob Description:As one of the largest Healthcare jobs placement agencies in the U.S., Supplemental Health Care has been partnering with Registered Nurses for more than 30 years. We’re now seeking Skilled Nursing Registered Nurses for openings at a hospital in Albuquerque, New Mexico. Our goal is to help open a range of options for our nurses and healthcare...
-
Skilled Nursing Registered Nurse
4 weeks ago
Albuquerque, United States Supplemental Health Care Full timeJob Description:As one of the largest Healthcare jobs placement agencies in the U.S., Supplemental Health Care has been partnering with Registered Nurses for more than 30 years. We’re now seeking Skilled Nursing Registered Nurses for openings at a hospital in Albuquerque, New Mexico. Our goal is to help open a range of options for our nurses and healthcare...
-
Skilled Nursing Registered Nurse
3 weeks ago
Albuquerque, United States Supplemental Health Care Full timeJob Description:As one of the largest Healthcare jobs placement agencies in the U.S., Supplemental Health Care has been partnering with Registered Nurses for more than 30 years. We’re now seeking Skilled Nursing Registered Nurses for openings at a hospital in Albuquerque, New Mexico. Our goal is to help open a range of options for our nurses and healthcare...
-
Registered Nurse
2 weeks ago
Albuquerque, New Mexico, United States Lovelace Women's Hospital Full timeJob DescriptionOverviewJoin our team as a day shift, part-time, Neonatal Intensive Care Unit (NICU) Registered Nurse in Albuquerque, NM. Fulfilling your purpose begins here: People First, Always. Here's how we take care of our people:Medical, vision, dental health insurance, health savings account / flexible spending, competitive pay, paid time off, 401k...
-
Registered Nurse
7 hours ago
Albuquerque, United States LHC New Full timeSummaryWe are hiring for a Registered Nurse to support our Albuquerque, NM patients!!At, At Home Healthcare, a part of LHC Group, we embrace a culture of caring, belonging, and trust and enjoy the meaningful connections that come from it: for the whole patient, their families, each other, and the communities we serve-it truly is all about helping people. You...
-
Registered Nurse
4 days ago
Albuquerque, United States N2S Healthcare Staffing Solutions LLC Full timeJob Title: RN - ORAddress:Albuquerque NM 87110Shift: 12 hrs dayGuaranteed hours: 36Pay Range:$45-$50License:Registered Nurse - State of New Mexico or Compact State Nursing License required.BLS certification within 90 days of hire.Education: Associate Degree in Nursing
-
Registered Nurse RN
4 weeks ago
Albuquerque, United States Spanish Trails Rehabilitation Suites Full timeWhy Join Spanish Trails as an RN - Registered Nurse? We are offering a $10,000 sign-on bonus!* We have 12-hour shifts - DAYS AND NIGHT SHIFT! We offer a nurse loan repayment program for your previous nurse loans for full-time employees! We have an awesome RN team to join! *Sign-on bonus for full-time, new hires and expires 6/30/2024! RN - Registered Nurse...
-
Registered Nurse RN
1 week ago
Albuquerque, United States Spanish Trails Rehabilitation Suites Full timeAlbuquerque, NM Why Join Spanish Trails as an RN - Registered Nurse? We are offering a $10,000 sign-on bonus!* We have 12-hour shifts - NIGHT SHIFT - full time! We offer a nurse loan repayment program for your previous nurse loans for full-time employees! We have an awesome RN team to join! *Sign-on bonus for full-time, new hires and expires...
-
Registered Nurse RN
3 weeks ago
Albuquerque, United States Spanish Trails Rehabilitation Suites Full timeAlbuquerque, NM Why Join Spanish Trails as an RN - Registered Nurse? We are offering a $10,000 sign-on bonus!* We have 12-hour shifts - DAYS AND NIGHT SHIFT! We offer a nurse loan repayment program for your previous nurse loans for full-time employees! We have an awesome RN team to join! *Sign-on bonus for full-time, new hires and expires...
-
Registered Nurse FT Nights
2 months ago
Albuquerque, United States Kindred Hospital Albuquerque Full timeRegistered Nurse FT Nights Albuquerque, New Mexico Facility Kindred Hospital Albuquerque Req ID 508097 Post Date 05/07/2024 Description $15K Sign on Bonus ScionHealth is committed to a culture of service excellence as demonstrated by our employees’ adherence to the service excellence principles of Pride, Teamwork, Compassion,...
-
Registered Nurse FT Nights
4 weeks ago
Albuquerque, United States Kindred Hospital Albuquerque Full timeRegistered Nurse FT Nights Albuquerque, New Mexico Facility Kindred Hospital Albuquerque Req ID 508097 Post Date 05/07/2024 Description $15K Sign on Bonus ScionHealth is committed to a culture of service excellence as demonstrated by our employees’ adherence to the service excellence principles of Pride, Teamwork, Compassion,...
-
Registered Nurse FT Nights
2 days ago
Albuquerque, United States Kindred Hospital Albuquerque Full timeRegistered Nurse FT Nights Albuquerque, New Mexico Facility Kindred Hospital Albuquerque Req ID 508102 Post Date 07/02/2024 Description ScionHealth is committed to a culture of service excellence as demonstrated by our employees’ adherence to the service excellence principles of Pride, Teamwork, Compassion, Integrity, Respect, Fun,...
