Registered Nurse
3 weeks ago
Title: Clinical Documentation Specialist (RN) (Fully Remote)
Location:Everett, WA 98201
Length: 13 Weeks
Shift: 5x8hr Days (8:00-16:30)
Note:
Experience as an RN in an acute care setting within the last 5 years AND 2-3 years Clinical Documentation Integrity experience in an 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.
Summary:
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 assignments.
The CDS's primary responsibility will be to obtain appropriate clinical documentation through an extensive review of provider, nursing, ancillary, and other patient caregivers' documentation, to ensure that appropriate documentation and reimbursement are received for the level of services rendered to patients.
The CDS exercises its 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, and the ability to work independently while interpreting and following CMS guidelines, organizational policies, and procedures.
COVID-19 Vaccine (Facility Guideline) Required - Medical/Religious Exemptions Only
Education & Certification:
Nursing is required, and a BLS in Nursing or healthcare.
RN License
BLS (AHA)
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