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.