Registered Nurse-Clinical Documentation Specialist III-Full Time (Remote)

About the position Responsibilities • Assess clinical documentation through extensive review of the medical record. • Interact with providers, nursing staff, and coding staff to ensure accurate reimbursement for services. • Conduct post-discharge reconciliation for comparative analysis of CDI specialist and final coding. • Formulate clinical documentation clarifications to improve documentation accuracy. • Query providers and APPs to clarify documentation in the EMR. • Maintain a query rate of at least 20% with an average of 20 reviews per day. • Participate in departmental education and training sessions. • Assist in precepting new CDI nurses and serve as a subject matter expert. • Collaborate with the healthcare team to resolve physician queries prior to discharge. • Analyze clinical information to identify gaps in physician documentation. • Identify ongoing documentation improvement opportunities. • Create and manage review processes and support tools. • Support the Quality department and uphold standards of conduct. • Act as a consultant to coding professionals for additional documentation needs. • Perform patient chart reviews during absences and when coverage is necessary. Requirements • Associates Degree in Nursing (Required) • Bachelors Degree in Nursing or healthcare related field (Preferred) • 5-6 years of Acute Care Nursing experience (Required) • 3-4 years of CDI experience (Required) • 3-4 years of ICD-10-CM & ICD-10-PCS experience (Required) • 1 year of 3M 360 experience (Preferred) • Registered Nurse (RN) license in Virginia (Required) • Certified Documentation Integrity Practitioner (CDIP) or Certified Clinical Document Specialist (CD) (Required) Nice-to-haves • Strong verbal communication skills • Knowledge of basic nursing principles and protocols • Proficient in clinical practice protocols for medical procedures and patient care • Time management and decision-making skills • Excellent organizational skills with attention to detail • Understanding of medical records organization and medical terminology • Ability to establish good customer relationships with trust and respect • Strong clinical assessment and critical thinking skills Benefits • Remote work eligibility for candidates in specified states • Competitive salary range • Opportunities for professional development and education • Supportive work environment with a focus on quality and customer serviceApply Now Apply Now