3 years of relevant experience in clinical documentation improvement or related field.
Licensed Registered Nurse with eligibility in New Hampshire.
Strong relationship-building skills to discuss clinical diagnoses confidently.
Excellent verbal and written communication skills.
Demonstrated interpersonal skills, including negotiation and conflict resolution.
Organizational skills with attention to detail and project management capabilities.
Proficient in data entry, analysis, word processing, and presentation software.
Responsibilities
Perform ongoing medical record reviews to ensure quality and completeness of documentation.
Initiate and maintain interactions with healthcare providers to gather detailed clinical information.
Ensure accurate reflection of severity of illness and services in medical records.
Review patient clinical pictures and assign working DRGs, entering them into the appropriate systems.
Track and analyze outcomes of documentation improvement programs and prepare progress reports.
Facilitate regular team meetings with coding staff to enhance collaboration.
Develop and deliver training programs on clinical documentation and coding issues.
Benefits
Remote work flexibility.
Opportunity to impact clinical documentation quality.
Engagement with a multidisciplinary healthcare team.
Professional development through training programs.
Access to ongoing updates on regulations and best practices.
Full Job Description
Clinical Documentation Specialist - RN, Remote
40 hours per week
Facilitates improvement in the overall quality, completeness and accuracy of medical record documentation. Educates members of the patient care team on documentation guidelines.
*CDI specific experience preferred
Responsibilities
Performs ongoing medical record reviews using documentation improvement guidelines. Evaluates overall quality and completeness of clinical documentation. Conducts follow-up reviews of clinical documentation.
Initiates and maintains interactions with physicians and mid-level providers on a concurrent basis to address the need for more detailed information in the medical record.
Ensure the severity of illness and level of services provided are accurately reflected in the medical record.
Reviews clinical picture of the patient and assigns a working DRG. Ensures the working DRG is entered in the appropriate database/IDX system and trends completion of DRG worksheets.
Establishes and maintains a system to track and analyze outcomes of documentation improvement program. Prepares regular outcomes progress reports and presents.
Facilitates and participates in regular team meetings with the Coding staff.
Works with inpatient coders to ensure appropriate DRG assignment and that reimbursement reflects the level of services rendered.
Uses performance improvement methodologies and education strategies to develop formal training and improvement programs for the staff concerning clinical documentation opportunities, coding and reimbursement issues. Provides ongoing updates as regulations change.
Educates Coding team members on clinical (diagnostic and therapeutic) updates on an ongoing basis.
Utilizes nursing and clinical knowledge to respond to payors concerning clinical denials, as assigned
Provides clinical documentation expertise to assist in resolving outpatient issues involving physician documentation.
Performs other duties as required or assigned.
Qualifications
Must have the ability to create and maintain strong relationships and confidently discuss clinical diagnoses.
Excellent verbal and written communication abilities required.
Demonstrated interpersonal skills, including negotiation, conflict resolution, follow-through and follow-up.
Must have good organizational skill including project management, with attention to detail and accuracy.
Must possess the ability to develop and deliver clinical education programs on clinical documentation improvement for the Medical Staff and Hospital Staff.
Must have the following computer competencies: data entry and analysis, word processing, and presentations.
Knowledge of DRG prospective payment systems, documentation & coding guidelines and compliance requirements preferred.
Current knowledge of DRGs and payment regulations preferred.
Up-to-date clinical knowledge, understand clinical picture of the patient condition and identify opportunities for improved documentation.
3 years of applicable experience.
Required Licensure/Certifications
Licensed Registered Nurse with NH eligibility
About Dartmouth-Hitchcock Medical Center
Dartmouth-Hitchcock Medical Center (DHMC) is a nonprofit academic health system that serves a population of 1.9 million in New England. DHMC includes a 396-bed tertiary care hospital, research and clinical facilities for the Geisel School of Medicine at Dartmouth, Norris Cotton Cancer Center, and the Dartmouth Institute for Health Policy and Clinical Practice. DHMC is the largest private employer in New Hampshire and is the only academic medical center in the state. The medical center is affiliated with the Geisel School of Medicine at Dartmouth and is part of Dartmouth-Hitchcock Health, a network of healthcare providers in New Hampshire and Vermont.
