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Registered Nurse, Clinical Documentation Specialist
Dartmouth-Hitchcock KeeneCore Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in clinical documentation improvement, including the ability to evaluate and enhance medical record accuracy and completeness. Proficient in developing educational programs and collaborating with healthcare teams to ensure compliance with documentation guidelines and DRG assignment.
Highest-signal resume keywords
Licensed Registered NurseClinical Documentation ImprovementDRG Prospective Payment SystemsExcellent Verbal And Written CommunicationProject Management
About the role
Key responsibilities & impact- Facilitate improvement in the quality, completeness, and accuracy of medical record documentation
- Educate patient care teams, Medical Staff, Hospital Staff, and Coding team members on documentation guidelines and clinical updates
- Perform ongoing and follow-up medical record reviews using documentation improvement guidelines
- Evaluate the quality and completeness of clinical documentation
- Interact concurrently with physicians and mid-level providers to obtain more detailed medical-record information
- Ensure severity of illness and level of services are accurately reflected in the medical record
- Review patients’ clinical pictures and assign working DRGs
- Enter working DRGs into the appropriate database/IDX system and track DRG worksheet completion
- Track and analyze documentation improvement outcomes; prepare and present regular progress reports
- Facilitate and participate in team meetings with Coding staff
- Collaborate with inpatient coders on DRG assignment and reimbursement accuracy
- Develop clinical documentation improvement training and performance-improvement programs
- Provide updates as regulations change
- Respond to payors concerning clinical denials
- Provide clinical documentation expertise for outpatient physician-documentation issues
- Perform other assigned duties
Requirements
What you’ll need- Licensed Registered Nurse with NH eligibility
- 3 years of applicable experience
- Ability to create and maintain strong relationships and confidently discuss clinical diagnoses
- Excellent verbal and written communication abilities
- Demonstrated interpersonal skills, including negotiation, conflict resolution, follow-through and follow-up
- Good organizational skills, including project management, attention to detail and accuracy
- Ability to develop and deliver clinical education programs on clinical documentation improvement
- Computer competencies in data entry and analysis, word processing, and presentations
- Up-to-date clinical knowledge and ability to understand the clinical picture of patient conditions and identify opportunities for improved documentation
- Knowledge of DRG prospective payment systems, documentation and coding guidelines, and compliance requirements preferred
- Current knowledge of DRGs and payment regulations preferred
- CDI-specific experience preferred
Benefits
Comp & perks- Loan repayment up to $20,000
- Generous tuition reimbursement
- Popular "earned time" plan
- Extensive CEU/Training programs
- Shared governance nursing model
- Rigorous, research-focused environment
- Continuing nursing education through an ANCC-accredited provider
- Equal opportunity employment
ATS Keywords
✓ Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Medical Record ReviewData Entry And AnalysisClinical Documentation GuidelinesDRG AssignmentDocumentation Improvement GuidelinesClinical Education Program DevelopmentRegulatory ComplianceClinical KnowledgeDocumentation And Coding GuidelinesPerformance Improvement Programs
Soft Skills
Interpersonal SkillsNegotiationConflict ResolutionAttention To DetailOrganizational Skills
Tools & Technologies
IDX SystemDatabase ManagementPresentation SoftwareWord Processing Software
Certifications & Qualifications
Registered Nurse License
Industry Keywords
Clinical Documentation ImprovementDRGCompliance RequirementsPatient Care TeamsCoding Staff