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Clinical Documentation Specialist, RN
Northeast Georgia Health System. Improve the overall quality and completeness of clinical documentation .
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in clinical documentation improvement, including DRG coding optimization and compliance with medical necessity standards. Strong analytical and communication skills are essential for collaborating with healthcare teams and ensuring accurate patient documentation.
Highest-signal resume keywords
Licensed RN in GeorgiaDRG Coding OptimizationICD10 Coding ConventionsClinical Documentation ImprovementLeadership Skills
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Clinical Documentation ImprovementDRG Coding OptimizationICD10 CodingMedical TerminologyPatient Severity AssessmentDocumentation QueriesCost-Containment StrategiesRevenue GenerationAnalytical ThinkingProblem-Solving
Soft Skills
Excellent Observation SkillsInterpersonal SkillsProfessionalismWritten CommunicationVerbal Communication
Tools & Technologies
3M 360 EncompassCoding Software
Certifications & Qualifications
CCDS CertificationCDIP Certification
Industry Keywords
Healthcare UtilizationRevenue ManagementMSDRG ReimbursementPatient SafetyUtilization Review
About the role
Key responsibilities & impact- Improve the overall quality and completeness of clinical documentation
- Perform admission and continued-stay reviews using CDMP guidelines
- Facilitate documentation modifications to accurately reflect patient severity and support appropriate reimbursement
- Conduct follow-up reviews and ensure clarifications are recorded in patient medical records
- Work concurrently with physicians during patient stays to obtain required documentation
- Refer quality, patient safety, and utilization concerns to CDI leadership, nursing, and case management
- Write compliant, non-leading clinical documentation queries
- Monitor documentation against core-measure quality indicators and address non-compliance
- Collaborate with physicians, nurses, case managers, and coding staff
- Assign working DRGs and update DRG worksheets through discharge
- Finalize diagnoses with attending physicians
- Educate patient-care teams and other audiences on documentation, coding, reimbursement, and performance methodologies
- Ensure medical-necessity documentation for levels of care and refer cases to Utilization Review
- Analyze DRGs to support appropriate payment recovery
- Participate in cost-containment and revenue-generation efforts
- Submit ideas for reducing cost or adding revenue
- Meet daily review assignments, deadlines, and productivity standards
- Adjust schedules and workloads to meet team performance needs
- Assist with special projects and other assigned duties
Requirements
What you’ll need- Licensed to practice as an RN in Georgia
- Associate's Degree
- Five (5) years in the practice of professional nursing
- Demonstrates aptitude in critical care or medical-surgical nursing
- Excellent observation skills, analytical thinking, problem-solving abilities, and written and verbal communication
- Working knowledge of DRG coding optimization strategies and clinical documentation requirements helpful
- Interpersonal skills and professionalism
- Computer skills and ability to be self-directed
- Familiarity with ICD10 coding conventions, anatomy and physiology, medical terminology, MSDRG reimbursement, and coding software, preferably 3M 360 Encompass
- Leadership skills required
- Maintains requirements contained in Remote Agreement
- Preferred: CCDS or CDIP certification
- Preferred: Bachelor's Degree in Nursing and additional education in Finance, Healthcare regulations, and diagnoses-procedure coding
- Preferred: Experience in Healthcare Utilization and Revenue Management
Benefits
Comp & perks- Remote work opportunity maintained through compliance with the Remote Agreement
- Equal Opportunity Employer