RN Nurse, Clinical Documentation Improvement Specialist
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Job Description
Clinical Documentation Improvement Specialist reviewing inpatient records and physician documentation for R1’s healthcare revenue-cycle technology. Improving coding accuracy, severity capture, and compliance.
Responsibilities:
- Conduct clinically based concurrent and retrospective reviews of inpatient medical records
- Evaluate clinical service documentation and identify opportunities to improve medical record documentation
- Conduct mortality reviews, PSI reviews, and other focused reviews identified by CDI leadership
- Facilitate and obtain appropriate physician documentation supporting severity of illness, expected risk of mortality, and complexity of care
- Initiate physician interaction through the physician query process and/or participation in physician rounding
- Educate physicians and other staff on documentation requirements, coding guidelines, and reimbursement policies
- Assign working DRGs and review patient records throughout hospitalization to ensure codes are reported at the highest specificity
- Collaborate with coders, auditors, quality improvement teams, and other stakeholders to resolve documentation issues and improve coding accuracy
- Participate in documentation improvement initiatives and formal and informal education plans for providers and the CDI team
- Stay updated on clinical documentation standards, coding rules, and regulatory requirements
Requirements:
- Associate’s Degree in Nursing required
- Bachelor’s Degree in Nursing preferred
- An active US RN license is required
- Front line CDI experience in an acute care hospital
- Three to five years of recent clinical work experience in the medical-surgical area, ICU, telemetry, and/or emergency department
- Knowledge or experience in electronic medical records (EMR) platforms and CDI platforms
- Highly skilled in CDI practices, coding, and documentation requirements related to quality outcomes, medical record data accuracy, and reimbursement
- Ability to stay abreast of CMS rules and regulations
- Clinical experience in ICU, medical-surgical, telemetry, or ED
- Knowledge of hospital coding code sets, policies and procedures, federal and state coding reimbursement guidelines, and Coding Clinic Guidelines
Benefits:
- Annual bonus plan at a target of 5.00%
- Competitive benefits package
- Opportunities to learn, collaborate across groups, and explore new career paths
- Opportunity to contribute, think boldly, and create meaningful work
- Reasonable accommodation support during the application process
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