RN - Clinical Documentation Specialist

Location Address:

1100 Central Avenue SE , Albuquerque, New Mexico , United States of America

Compensation Pay Range:

Minimum Offer $:

62400

Maximum Offer for this position is up to $:

95305.6

Now hiring a

RN - Clinical Documentation Specialist

Summary:

This position is expected to assist medical staff providers with documentation in the medical record. Will be responsible to review physician documentation daily; keep track of patient diagnosis and procedures to reflect the level of service provided. Will work independently and must be able to develop, schedule and prioritize the workload to ensure all work is completed. Must be flexible to assist with coverage issues and a team player in consultation with other reviewers and HIM coders. Excellent communication skills are essential for daily interaction and collaboration with physicians and staff to ensure that clinical information in the medical record is present and accurate to support that the appropriate clinical severity is captured for the level of service rendered. This position may encounter resistance due to the perception that information is already adequately documented in the medical record. It requires experience and confidence to address all types of clinical documentation issues and regulatory requirements. The individual must be assertive and tactful to obtain medical staff cooperation

How you belong matters here.

We value our employees' differences and find strength in the diversity of our team and community.

At Presbyterian, it's not just what we do that matters. It's how we do it - and it starts with our incredible team. From Information Technology to Food Services and beyond, our non-clinical employees make a meaningful impact on the healthcare provided to our patients and members.

Why Join Us

Type of Opportunity:

Full time

Job Exempt:

Yes

Job is based :

Presbyterian Hospital

Work Shift:

Weekday Schedule Monday-Friday (United States of America)

• Benefits: We offer a wide range of benefits including medical, wellness program, vision, dental, paid time off, retirement and more for FT employees.
• Benefits: PRN/PT (working less than a .45 FTE) employee benefits available for this position such as medical, gym memberships and an employee wellness program.
• Remote: Open to remote applicants in the United States, except for the following states: Wyoming, North Dakota, and Ohio

Ideal Candidate/Prefer Qualifications/or Why this position is unique

Clinical Documentation and Compliance Specialist-ABQ*Associates degree in Nursing and 5 years clinical experience in an acute care facility or Bachelors degree with 2 yrs CDI experience required. *Achieve CCDS (Certified Clinical Documentation Specialist) within 3 years employment as Clinical Documentation Specialist (CDS). *Working knowledge of medical terminology, ICD-10, CPT, HCPCS, DRG, disease processes and related procedures required. *Up to date clinical skills and current working knowledge of pathology and pharmacology impacts on care required. *Experience with database, spreadsheet and word process required. *Detail and results oriented, with the ability to maintain accurate, detailed and organized records essential. UPDATED 8/21/22

All benefits-eligible Presbyterian employees receive a comprehensive benefits package that includes medical, dental, vision, short-term and long-term disability, group term life insurance and other optional voluntary benefits.

Wellness
Presbyterian's Employee Wellness rewards program is designed to provide you with engaging opportunities to enhance your health and activate your well-being. Earn gift cards and more by taking an active role in our personal well-being by participating in wellness activities like wellness challenges, webinar, preventive screening and more.

Why work at Presbyterian?
As an organization, we are committed to improving the health of our communities. From hosting growers' markets to partnering with local communities, Presbyterian is taking active steps to improve the health of New Mexicans.

About Presbyterian Healthcare Services
Presbyterian exists to improve the health of patients, members, and the communities we serve. We are locally owned, not-for-profit healthcare system of nine hospitals, a statewide health plan and a growing multi-specialty medical group. Founded in New Mexico in 1908, we are the state's largest private employer with nearly 14,000 employees - including more than 1600 providers and nearly 4,700 nurses.

Our health plan serves more than 580,000 members statewide and offers Medicare Advantage, Medicaid (Centennial Care) and Commercial health plans.

Inclusion and Diversity
Our culture is one of knowing and respecting our patients, members, and each other. We capture this in our Promise and CARES commitments.

AA/EOE/VET/DISABLED. PHS is a drug-free and tobacco-free employer with smoke free campuses.