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RN CLINICAL DOCUMENT SPEC in Albuquerque, NM for UNM Hospital
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RN CLINICAL DOCUMENT SPEC
Position Summary:Responsible for concurrent review (during the patient stay) of appropriate and complete clinical documentation in the medical record to support services ordered and/or received, support primary diagnosis, secondary diagnoses, and co-morbidities to improve medical record physician documentation to appropriately support the severity of patient illness and resource consumption. Responsible for addressing and communicating appropriate documentation findings with physicians and other caregivers as necessary via written queries and/or verbal communication. Responsible for follow up to obtain accurate and complete documentation in the medical record during the hospitalization. Utilization of abstracting and data entry


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Case Management Society of America
5034A Thoroughbred Lane
Brentwood, TN 37027