Improving the overall quality and completeness of clinical documentation
Modifying clinical documentation through interaction with Physicians, Nursing staff, other patient caregivers, and medical records coding staff
Ensuring appropriate reimbursement is received for services rendered
Educating all members of the patient care team on clinical documentation
Conducting admission/continued stay reviews using the Compliant Documentation Program Management (CDMP) guidelines
Monitoring documentation against "core measure" quality indicators and addressing non-compliance documentation
Collaborating with coding staff to assign the "working" DRG to contribute for IDT Rounds
Maintaining a leadership role to ensure compliant documentation
Organizing and performing work effectively and efficiently

Current RN Licensure in the State of Georgia
Associates Degree
Minimum of five (5) years in the practice of professional nursing
CCDS or CDIP certifications preferred
Bachelor's Degree in Nursing preferred
Additional education in Finance, Healthcare regulations, and diagnoses-procedure coding preferred
Experience in Healthcare Utilization and Revenue Management preferred
Working knowledge of DRG coding optimization strategies and clinical documentation requirements
Familiar with ICD10 coding conventions, anatomy and physiology, medical terminology, MSDRG reimbursement, coding software
Excellent analytical thinking, problem-solving abilities, and written and verbal communication skills

Registered Nurse, Clinical Documentation Specialist – CDIP, CCDS

Key skills