Registered Nurse Clinical Documentation Specialist

4 weeks ago


Kenosha, United States Froedtert South, Inc. Full time

**POSITION PURPOSE**- Performs concurrent clinical documentation review to promote complete capture of documentation needed to accurately code level of clinical service and patient acuity. Works collaboratively with physicians and coders.-
**MINIMUM EDUCATION REQUIRED**- Associate Degree in Nursing-
**MINIMUM EXPERIENCE REQUIRED**- 3 - 5 Years-
**LICENSES / CERTIFICATIONS REQUIRED**- Licensure to be eligible to practice as a Registered Nurse in the State of Wisconsin.-
- CCS (Certified Coding Specialist) preferred.-
**KNOWLEDGE, SKILLS & ABILITIES REQUIRED**- 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.-
- Previous acute care clinical experience preferred.-
**PRINCIPLE ACCOUNTABILITIES AND ESSENTIAL DUTIES**- Performs concurrent medical record review of defined bedded patients, documents provisional DRG, and documents potential working DRGs up until patient discharge.-
- Facilitates necessary clinical documentation in the medical record through verbal and written communication with clinicians.-
- Evaluates clinical documentation patterns to identify areas for improvement, identifies changes which will proactively collect required documentation, and develops reports to monitor program success and opportunities for concentrated focus.-
- Educates patient care team members regarding clinical documentation requirements and coding guidelines and provides feedback on patient care team members’ clinical documentation.-
- Works collaboratively with other disciplines to achieve the most precise and reflective final coding.Location: Froedtert South, Inc. - MEDICAL RECORDS

Schedule: Full-time, Varied, 80



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