RN - Clinical Documentation and Compliance Specialist
Presbyterian Healthcare Services

RN - Clinical Documentation and Compliance Specialist Albuquerque, NM

Full Time Albuquerque, NM 46816 - 70105 USD ANNUAL Today
Job description

We are hiring a Remote Clinical Documentation and Compliance Specialist for Presbyterian Hospital!

This position is expected to assist medical staff providers with documentation in the medical record. Will be responsible to review physician documentation daily; keep track of patient diagnosis and procedures to reflect the level of service provided. Will work independently and must be able to develop, schedule and prioritize the workload to ensure all work is completed. Must be flexible to assist with coverage issues and a team player in consultation with other reviewers and HIM coders. Excellent communication skills are essential for daily interaction and collaboration with physicians and staff to ensure that clinical information in the medical record is present and accurate to support that the appropriate clinical severity is captured for the level of service rendered. This position may encounter resistance due to the perception that information is already adequately documented in the medical record. It requires experience and confidence to address all types of clinical documentation issues and regulatory requirements. The individual must be assertive and tactful to obtain medical staff cooperation

Type of Opportunity: Full Time
FTE: 1.000000
Exempt: Yes
Work Schedule: Weekday Schedule Monday-Friday
  • Associates degree in Nursing and 5 years clinical experience in an acute care facility or Bachelors degree with 2 yrs CDI experience required.
  • Achieve CCDS (Certified Clinical Documentation Specialist) within 3 years employment as Clinical Documentation Specialist (CDS).
  • Working knowledge of medical terminology, ICD-10, CPT, HCPCS, DRG, disease processes and related procedures required.
  • Up to date clinical skills and current working knowledge of pathology and pharmacology impacts on care required.
  • Experience with database, spreadsheet and word process required.
  • Detail and results oriented, with the ability to maintain accurate, detailed and organized records essential.


We offer more than the standard benefits!
Presbyterian employees gain access to a robust wellness program, including free access to our on-site and community-based gyms, nutrition coaching and classes, wellness challenges and more!

Learn more about our employee benefits:


Why work at Presbyterian?
As an organization, we are committed to improving the health of our communities. From hosting growers' markets to partnering with local communities, Presbyterian is taking active steps to improve the health of New Mexicans. For our employees, we offer a robust wellness program, including free access to our on-site and community-based gyms, nutrition coaching and classes, wellness challenges and more.

Presbyterian's story is really the story of the remarkable people who choose to work here. The hard work of our physicians, nurses, employees, board members and volunteers grew Presbyterian from a tiny tuberculosis sanatorium to a statewide healthcare system that serves more than 875,000 New Mexicans.

About Presbyterian Healthcare Services
Presbyterian Healthcare Services exists to improve the health of patients, members and the communities we serve. We are a locally owned, not-for-profit healthcare system of nine hospitals, a statewide health plan and a growing multi-specialty medical group. Founded in New Mexico in 1908, we are the state's largest private employer with nearly 14,000 employees - including more than 1,600 providers and nearly 4,700 nurses.

Our health plan serves more than 580,000 members statewide and offers Medicare Advantage, Medicaid (Centennial Care) and Commercial health plans.

About Our Regional Delivery System
Presbyterian's Regional Delivery System is a network of six hospitals and medical centers throughout rural New Mexico including locations in Clovis, Espanola, Ruidoso, Santa Fe, Socorro and Tucumcari. Our regional facilities are home to more than 1,600 clinical and non-clinical employees who help make Presbyterian the state's largest private employer with nearly 14,000 statewide employees. With a variety of services ranging from general surgery to pediatrics to heart and cancer care, our regional employees are proud to provide close-to-home care for their communities.

We are part of New Mexico's history - and committed to its future. That is why we will continue to work just as hard and care just as deeply to serve New Mexico for years to come.

About New Mexico
New Mexico continues to grow steadily in population and features a low cost-of living.

Varied landscapes bring filmmakers here from around the world to capture a slice of the natural beauty New Mexicans enjoy every day. Our landscapes are as diverse as our culture - from mountains, forests, canyons, and lakes, to caverns, hot springs and sand dunes.

New Mexico offers endless recreational opportunities to explore and enjoy an active lifestyle. Venture off the beaten path, challenge your body in the elements, or open yourself up to the expansive sky. From hiking, golfing and biking to skiing, snowboarding and boating, it's all available among our beautiful wonders of the west.

AA/EOE/VET/DISABLED. PHS is a drug-free and tobacco-free employer with smoke free campuses.

RN - Clinical Documentation and Compliance Specialist
Presbyterian Healthcare Services

Albuquerque, NM
Dale Maxwell
$1 to $5 billion (USD)
10000+ Employees
Nonprofit Organization
Health Care Services & Hospitals
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