Clinical Documentation Specialist (Registered Nurse) - Remote IL id-12643

December 23, 2024

Job Description

Clinical Documentation Specialists provide concurrent review of the clinical documentation in the medical records. Provides education to physicians and mid-level providers to ensure accurate coding and appropriate reimbursement.

Department: Medical Records

Hours: Day Shift

Starting Salary: $63,564.80+, pay based on applicable experience.

*RN Required.

Responsibilities

Assessment - Collects pertinent data and information relative to the patient's health or the situation. Recognizes normal and abnormal findings when gathering data., Conducts follow-up on unanswered queries during the patient stay, as needed, to obtain a response to open queries.

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Works collaboratively with the healthcare team to facilitate documentation within the medical record that supports patient’s severity of illness and risk of mortality, Conducts initial and extended-stay concurrent reviews on all selected admissions for opportunities to clarify documentation in the medical record for accurate reflection of severity of illness, and documents findings within the CDS tracking software, denoting all key information utilized in the tracking process, Coordination of Care - Plans and evaluates care in collaboration with appropriate disciplines., Demonstrated creativity and enthusiasm while pursuing the goals of the department and the organization, Demonstrates an understanding of the importance of and makes an effort to capture all appropriate secondary diagnoses for quality ratings/profiling purposes., Diagnosis - Analyzes assessment data to determine actual or potential diagnosis, problems, issues., Evaluation - Evaluates progress toward attainment of goals and outcomes.

Reports data and outcomes to others as appropriate., Identifies need to clarify documentation in records, and utilizes strong communication skills with physician, physician extender, case manager, utilization reviewer, nurse or other healthcare professionals, utilizing appropriate querying tools to capture needs documentation. , Implementation - Implements care or work plan in alignment with the plan and approved safety, infection control,and department/organization standards., Knowledge - In collaboration with leaders, actively pursues required knowledge and skills through orientation activities specific to the position, reading current literature and seeking new learning opportunities., Maintains the ability to be flexible, and prioritizes daily responsibilities, Outcomes Identification - Identifies expected outcomes for a plan individualized to the patient or situations., Performs a thorough chart review to identify comorbidities/complications, and documents these appropriately within the concurrent Clinical Documentation Specialist (CDS) tracking software., Planning - Develops a plan that prescribes strategies to attain expected, measurable outcomes.

Queries the medical staff and other care givers as necessary via written/verbal communication., Relationships - Establishes effective working relationships with peers, physicians, and other members of the health care / work team. Identifies and confers with appropriate resources regarding patient / work decisions., Reviews the progress of the concurrent documentation review program, through interpretation of process and operational reports, financial and compliance reports, and quality ratings reports. Able to identify areas of focus through report analysis. , Serves as a resource to physicians and administration regarding issues related to the appropriateness of inpatient DRG assignment. Provides information and informal in-services as necessary to physicians and ancillary staff., Teaching - Employs teaching strategies to promote health and a safe environment.

Clinical Documentation Specialist (Registered Nurse) - Remote IL id-12643

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Common Interview Questions And Answers

1. HOW DO YOU PLAN YOUR DAY?

This is what this question poses: When do you focus and start working seriously? What are the hours you work optimally? Are you a night owl? A morning bird? Remote teams can be made up of people working on different shifts and around the world, so you won't necessarily be stuck in the 9-5 schedule if it's not for you...

2. HOW DO YOU USE THE DIFFERENT COMMUNICATION TOOLS IN DIFFERENT SITUATIONS?

When you're working on a remote team, there's no way to chat in the hallway between meetings or catch up on the latest project during an office carpool. Therefore, virtual communication will be absolutely essential to get your work done...

3. WHAT IS "WORKING REMOTE" REALLY FOR YOU?

Many people want to work remotely because of the flexibility it allows. You can work anywhere and at any time of the day...

4. WHAT DO YOU NEED IN YOUR PHYSICAL WORKSPACE TO SUCCEED IN YOUR WORK?

With this question, companies are looking to see what equipment they may need to provide you with and to verify how aware you are of what remote working could mean for you physically and logistically...

5. HOW DO YOU PROCESS INFORMATION?

Several years ago, I was working in a team to plan a big event. My supervisor made us all work as a team before the big day. One of our activities has been to find out how each of us processes information...

6. HOW DO YOU MANAGE THE CALENDAR AND THE PROGRAM? WHICH APPLICATIONS / SYSTEM DO YOU USE?

Or you may receive even more specific questions, such as: What's on your calendar? Do you plan blocks of time to do certain types of work? Do you have an open calendar that everyone can see?...

7. HOW DO YOU ORGANIZE FILES, LINKS, AND TABS ON YOUR COMPUTER?

Just like your schedule, how you track files and other information is very important. After all, everything is digital!...

8. HOW TO PRIORITIZE WORK?

The day I watched Marie Forleo's film separating the important from the urgent, my life changed. Not all remote jobs start fast, but most of them are...

9. HOW DO YOU PREPARE FOR A MEETING AND PREPARE A MEETING? WHAT DO YOU SEE HAPPENING DURING THE MEETING?

Just as communication is essential when working remotely, so is organization. Because you won't have those opportunities in the elevator or a casual conversation in the lunchroom, you should take advantage of the little time you have in a video or phone conference...

10. HOW DO YOU USE TECHNOLOGY ON A DAILY BASIS, IN YOUR WORK AND FOR YOUR PLEASURE?

This is a great question because it shows your comfort level with technology, which is very important for a remote worker because you will be working with technology over time...

DISCLAIMER

Other Jobs You May Be Interested In

Common Interview Questions And Answers

1. HOW DO YOU PLAN YOUR DAY?

2. HOW DO YOU USE THE DIFFERENT COMMUNICATION TOOLS IN DIFFERENT SITUATIONS?

3. WHAT IS "WORKING REMOTE" REALLY FOR YOU?

4. WHAT DO YOU NEED IN YOUR PHYSICAL WORKSPACE TO SUCCEED IN YOUR WORK?

5. HOW DO YOU PROCESS INFORMATION?

6. HOW DO YOU MANAGE THE CALENDAR AND THE PROGRAM? WHICH APPLICATIONS / SYSTEM DO YOU USE?

7. HOW DO YOU ORGANIZE FILES, LINKS, AND TABS ON YOUR COMPUTER?

8. HOW TO PRIORITIZE WORK?

9. HOW DO YOU PREPARE FOR A MEETING AND PREPARE A MEETING? WHAT DO YOU SEE HAPPENING DURING THE MEETING?

10. HOW DO YOU USE TECHNOLOGY ON A DAILY BASIS, IN YOUR WORK AND FOR YOUR PLEASURE?

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