• RN Documentation Specialist II - Clinical Documentation Integrity / Audits

    Job Locations US-MT-Kalispell
    Requisition ID
    Nursing - Hospital Staff
    Pay Period Status
    Monday - Friday, mostly 8-4:30 with some flexibility
  • Overview

    The RN Documentation Specialist II position communicates with physicians regarding documentation in order to obtain an accurate and complete clinical record of the patient care.  Ensures appropriate Diagnosis Related Grouper (DRG) assignment and accurate severity of illness and risk of mortality profiles. Educates health care providers and serves as a resource regarding documentation issues.  Complies with Kalispell Regional Healthcare’s (KRH) compliance program initiatives.


    1. *Appropriately identifies and screens the medical records of all admissions per department procedure. Assigns a working principal diagnosis, lists all secondary diagnoses, procedures performed, and designates working DRGs, per Coding Guidelines. Identifies complications and co-morbidities significant to the patient’s present hospitalization.
    2. *Ensures all secondary diagnoses are monitored, treated, evaluated, and clinically substantiated. Ensures any conditions occurring with patients have documented corresponding diagnoses.
    3. *Identifies query opportunities and appropriately queries providers as necessary. Follows the most recent “Guidelines for Achieving a Compliant Query Practice” recommendations.  Conducts all interactions in a clear, concise, and professional manner.    
    4. *Regularly reviews patient charts and apprises staff of any DRG and/or length of stay changes.
    5. *Exhibits proficiency with 3M Coding software.
    6. *Reviews Coder feedback per department protocol. Stays current with Coding Guideline updates. Participates in sharing information with CDI group and coders, as requested.
    7. *Meets productivity standards as outlined in department procedures.
    8. *Communicates professionally and concisely with providers, clinic offices, and ancillary department staff, as needed.


    1. RN license required, BSN degree preferred.
    2. Must obtain one (1) of the listed certifications within one (1) year of hire: CCDS, CCS, CDIP, RHIT, or RHIA
    3. Knowledge of classification and nomenclature of anatomy and physiology, medical terminology, and health information management procedures and practices required.
    4. Possess understanding of ICD-10-CM and ICD-10-PCS coding guidelines and practices.
    5. Minimum of four (4) year’s coding or clinical experience preferred.
    6. Must possess excellent communication and customer relations skills.
    7. Must be self-motivated, possess organizational and problem-solving skills, experience setting priorities and function as a team member.
    8. Possess and maintain computer skills to include working knowledge of Microsoft Office Suite and ability to learn other software as needed.


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