Experienced USRN – Emergency, OR, Surgical Ward, or ICU Nurse | 100K Sign-On Bonus

Requirements

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Active PHRN and USRN License

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USRN License (Any state)

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

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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

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

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

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

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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.

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

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

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

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

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

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