ICD-10/ICD-9

coding, CPT coding, and DRG assignment. Review medical records, clinical documentation, and healthcare data to ensure accuracy and completeness for reimbursement and quality reporting purposes. Utilize EMR/EHR systems such as Epic, Cerner, Athenahealth, or eClinicalWorks to document patient information efficiently. Conduct utilization review and management activities to optimize resource use while maintaining compliance with CMS standards. Collaborate with interdisciplinary teams—including nursing, therapy, social work, and physicians—to facilitate discharge planning and case management. Ensure adherence to HIPAA regulations and maintain confidentiality of patient information during all documentation review processes. Provide education and guidance on clinical documentation improvement initiatives to staff members. Monitor compliance with NCQA standards and other accreditation requirements related to medical records management. Participate in quality assurance activities related to medical management, coding accuracy, and documentation review processes. Requirements Valid Registered Nurse (RN) license with current state licensure. Extensive experience with MDS coordination in settings such as nursing homes, hospitals (Level I/II Trauma Centers), or hospice care environments. Proficiency in EMR/EHR systems. Strong knowledge of

ICD-10/ICD-9/ICD

coding systems, CPT coding, DRG assignment, and Medicare regulations. Familiarity with managed care processes, utilization review/management, case management, and discharge planning procedures. Experience working within inpatient or outpatient settings such as ICU/PICU/ER or primary care clinics is highly desirable. Knowledge of healthcare standards including NCQA standards and HIPAA compliance requirements. Ability to interpret physiology, anatomy, medical terminology, and clinical documentation for accurate assessments. Excellent organizational skills with attention to detail in medical records review and documentation improvement initiatives. Strong communication skills to collaborate effectively across multidisciplinary teams and provide staff education on documentation best practices. This position offers a dynamic environment where your expertise in nursing practice combined with health information management will directly impact patient outcomes and organizational compliance standards.

Pay:

$33.00 - $39.00 per hour

Benefits:

401(k) matching Dental insurance Disability insurance Health insurance Life insurance Paid time off Vision insurance

Work Location:

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