Clinical Documentation Improvement Specialist Registered Nurse

The Clinical Documentation Improvement (CDI) Specialist is responsible for facilitating improvement of the overall quality and completeness of medical record documentation. CDI Specialist role is to facilitate quality outcomes and revenue integrity through capture of accurate, complete, and compliant documentation through coordination, collaboration, and communication with related disciplines to address and integrate opportunities for documentation improvement and provider education.

Essential Functions and Responsibilities

Ensures the accuracy and completeness of clinical information used for measuring and reporting physician and hospital outcomes. Performs daily chart reviews seeking opportunity to clarify (query) documentation with the health record to capture accurate, complete and compliant documentation. Assigns Working DRGs & ICD10 CM/PCS codes. Facilitates necessary documentation in the medical record through extensive interaction with physicians, nursing staff, other patient caregivers, and collaboration with HIM/Coding staff to ensure the most appropriate reimbursement is achieved for the level of service rendered to all patients. Educates all members of the patient care team regarding clinical documentation needs, changes to clinical documentation guidelines, coding and reimbursement issues, and pay for performance documentation requirements on an on-going basis.

Required

• Current Registered Nurse License in the State of practice Minimum 5 years of acute hospital care experience Certified Clinical Documentation Specialist (CCDS), or obtain certification when eligible as defined by the Association of Clinical Documentation Improvement Specialists – ACDIS, and maintenance of continuing education requirements Member (or obtain within 1 year of service) with the Association of
• Clinical
• Documentation
• Improvement
• Specialists (ACDIS)
• Preferred: CDIP certification Experience with CDI Software Tools (i.e. 3M 360, JATA, ChartWise, other) Knowledge of coding/documentation and billing regulations related to commercial insurance, Medicaid and Medicare. (i.e., APR-DRG, MS-DRG, Medicare, Medicaid & Managed Care) Experience in Utilization Management/Case Management, Critical Care, and patient outcomes/quality management preferred. Inpatient coding experience desired. Equal Opportunity Employer of Minorities/Females/Disabled/Veterans