USRN with Medical-Surgical : ICU, Telemetry & Emergency Department Experience

Requirements

Bachelors degree in Nursing

Active PRC and USRN License

USRN License from Compact State / s

Have 3 to 5 years of clinical experience in medical-surgical areas; ICU, telemetry, Emergency Department

Knowledge about diagnoses, signs & symptoms, diagnostic tests and management expected for conditions such as DM, HTN, CHF, CVA, sepsis, encephalopathy, AKI, CKD, etc.

Key Responsibilities

Reviews clinical documentation to ensure it accurately reflects the patient's severity of illness, risk of mortality, and complexity of care.

Shares review findings with leadership, CDI team, and other relevant staff; recommends corrective actions when needed.

Performs focused reviews on specific areas like mortality rates, patient safety indicators (PSIs), and other priority projects.

Provides ongoing education and training to the CDI team and related departments about documentation trends and best practices. Also leads the onboarding of new CDI specialists.

Acts as a subject matter expert in CDI, coding rules, and compliance, identifying risks and opportunities for improvement.

Applies coding guidelines and policies to assign accurate DRGs and reviews patient records throughout hospitalization to ensure proper coding.

Collaborates with physicians to clarify unclear or missing documentation through queries or during rounds.

Works with HIMS coders to ensure accurate diagnosis / procedure codes and complete documentation for final DRG assignment and quality outcomes.

Builds and maintains strong relationships with providers to support documentation improvement efforts.

Leads documentation improvement initiatives and participates in related department or organizational projects.