RN – Clinical Documentation Improvement Specialist

Responsibilities

• Providing improvement in the overall quality and completeness of medical record documentation
• Obtain appropriate clinical documentation through extensive interaction with physicians, nursing staff, other patient caregivers, and coding staff
• Ensure proper reimbursement is received for the level of service rendered to patients
• Educate members of the organization on documentation guidelines and improvement efforts

Requirements

• Associate Degree in Nursing required
• Bachelors Degree in Nursing preferred
• Clinical Documentation Improvement Specialist (CDIS) experience and/or training preferred
• Current registered nurse (RN) license or temporary permit from the State of Nebraska required

Hard Skills

• clinical documentation improvement
• medical record documentation
• reimbursement processes

Soft Skills

• communication
• interpersonal skills
• educational skills

Certifications & Qualifications

• registered nurse (RN) license
• Clinical Documentation Improvement Specialist (CDIS)

Industry Keywords

• documentation guidelines
• patient care
• healthcare compliance