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USRN (Clinical Documentation) | With signing bonus
HRTXTaguig, Metro Manila, Philippines30+ days ago
Job descriptionReviews 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.
Minimum Requirements
- Bachelor's degree in nursing
- Three to five (3-5) years of recent clinical work experience in the medical-surgical area, ICU, telemetry, or emergency department
- Active USRN license
- Solid background in fundamentals of nursing and medical & surgical nursing
- Knowledge about diagnoses, signs & symptoms, diagnostic tests and management expected for conditions such as DM, HTN, CHF, CVA, sepsis, encephalopathy, AKI, CKD, etc.
- No BPO experience required as long as you meet the above qualifications
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Clinical Documentation • Taguig, Metro Manila, Philippines
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