Clinical Documentation Spec. (Registered Nurse) On-Site

University Medical Center Of El Paso • El Paso, TX

379d

About The Position

The Clinical Documentation Specialist (Registered Nurse) plays a crucial role in enhancing the quality of clinical documentation by collaborating with healthcare professionals to ensure accurate representation of patient care. This position focuses on improving documentation practices to reflect the appropriate clinical severity and level of service provided during patient encounters, thereby supporting compliance with regulatory standards.

Requirements

• Three years of related clinical experience in an inpatient setting required.
• Currently licensed as a Registered Nurse.
• Strong interpersonal skills and ability to communicate effectively with others.
• Excellent verbal and written communication skills.
• Proficiency in organization, planning, and computer usage including database and spreadsheet analysis.
• Knowledge of ICD-10, MS-DRG, CPT-4, E&M, and APC regulations.
• Understanding of federal, state, and private payer regulations.

Nice To Haves

• Certified Coding Specialist (CCS) or Certified Documentation Improvement Practitioner (CDIP) or Certified Clinical Documentation Specialist (CCDS) preferred.

Responsibilities

• Facilitate modifications to inpatient and outpatient clinical documentation through interaction with physicians and healthcare team members.
• Ensure appropriate clinical severity is captured for all encounters.
• Stay updated on CMS rules and regulations and incorporate changes into daily practice.
• Assess, evaluate, and teach documentation best practices to healthcare staff.
• Collaborate with the healthcare team to improve documentation quality and compliance.

Benefits

• Full-time position with a standard schedule of Monday to Friday, days.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Industry: Hospitals
• Education Level: No Education Listed