Tenet Healthcare Corporation·Anniston, Alabama
The role involves reviewing medical records to facilitate accurate physician documentation regarding clinical conditions and procedures to support severity of illness and risk of mortality. The nurse will also educate the patient care team and formulate queries to resolve conflicting or missing documentation.
Responsible for reviewing medical records to facilitate and obtain appropriate physician documentation for any clinical conditions or procedures to support the appropriate severity of illness, expected risk of mortality, and complexity of care of the patient, by improving the quality of the physicians’ clinical documentation. Exhibits a sufficient knowledge of clinical documentation requirements, MS-DRG Assignment, and clinical conditions and/or procedures.
Educates members of the patient care team regarding documentation guidelines, including the following: attending physicians, allied health practitioners, nursing, and case management.
Include the following. Others may be assigned.
Completes initial medical records reviews of patient records within 24-48 hours of admission for a specified patient population to: (a) evaluate documentation to assign the principal diagnosis, pertinent secondary diagnoses, and procedures for accurate MS-DRG assignment, risk of mortality and severity of illness; and (b) record in business partner designated CDI tool and/or host medical record system.
Conducts follow-up reviews of patients every 24-48 hours or as needed up through discharge to support assigned working MS-DRG assignment upon patient discharge, as necessary.
Formulate physician queries regarding missing, unclear, or conflicting health record documentation by requesting and obtaining additional documentation within the health record, as necessary.
Collaborates with providers, case managers, nursing staff and other ancillary staff regarding documentation and to resolve physician queries prior to discharge.
2.CDI
Communicates/Completes Clinical Documentation Integrity (CDI) activities and coding issues (lacking documentation, physician queries, etc.) for appropriate follow-up, provider education and DRG Miss-Match reconciliation.
Assists with Provider education, rounding and communication regarding open queries for resolution.
Stays current with AHA Official Coding and Reporting Guidelines, CMS and other agency directives for ICD10-CM and PCS coding. Attends CDI Boot camp, CDI/coding trainings annually and quarterly for inpatient coding. Attends monthly education lecture series (MELS) and all CDI/coding assigned learn share modules as well as any additional required CDI education.
4. Assist in training department staff new to CDI
5. Performs other duties as assigned
Knowledge, skills, abilities
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
CDI Specialist must display teamwork and commitment while performing daily duties
Must demonstrate initiative and discipline in time management and medical record review.
Travel may be required to meet the needs of the facilities.
Proficient knowledge of disease pathophysiology and drug utilization
Intermediate knowledge of MS-DRG classification and reimbursement structures
Critical thinking, problem solving and deductive reasoning skills.
Effective written and verbal communication skills
Excellent computer skills including MS Word/Excel
Knowledge of coding compliance and regulatory standards
Excellent organizational skills for initiation and maintenance of efficient workflow
Regular and reliable attendance
Capacity to work independently in facility on-site setting.
Capacity to work independently in a virtual office setting if required for specific assignment.
Exhibit flexibility as needed to meet program needs.
Understand and communicate documentation strategies.
Recognize opportunities for documentation improvement.
Formulate clinically, compliant credible queries.
Ability to successfully comply to robust auditing and CDI program monitoring
Ability to apply coding conventions, official guidelines, and Coding Clinic advice to health record documentation.
Conifer requires its candidates, as applicable and as permitted by law, to obtain and provide confirmation of all required vaccinations and screenings prior to the start of employment. This may include, but is not limited to, the COVID-19 vaccination, influenza vaccination, and/or any future required vaccines and screenings.
Education / Experience
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Ability to sit for extended periods of time.
Ability to stand for extended periods of time.
Must be able to efficiently use computer keyboard and mouse.
Good visual acuity
The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
As a part of the Tenet and Catholic Health Initiatives family, Conifer Health brings 30 years of healthcare industry expertise to clients in more than 135 local regions nationwide.
We help our clients strengthen their financial and clinical performance, serve their communities, and succeed at the business of healthcare.
Conifer Health helps organizations transition from volume to value-based care, enhance the consumer and patient healthcare experience and improve quality, cost, and access to healthcare.
Are you ready to be part of our solutions?
Welcome to the company that gives you the resources and incentives to redefine healthcare services, with a competitive benefits package and leadership to take your career to the next step!
Candidates must hold an active Registered Nurse license or MD/FMD license and possess at least two years of nursing or provider experience in acute care settings. Proficiency in MS-DRG classification and strong communication skills are required to succeed in this hybrid role.
Market context
Nursing roles in Alabama typically stay active across hospitals, clinics, and other care settings, especially when units need licensed RNs who can start quickly. These positions can be competitive because employers often look for current Alabama or multistate RN licensure, BLS, and education that meets the unit’s needs, with BSN or specialty certifications sometimes preferred. Review the unit-specific certification timeline and compare the AI-summarized requirements and benefits here with the original posting to save research time before applying.