CDI Specialist RN

Job Summary

Provides thorough concurrent review of medical record clinical documentation to capture documented and potential principal diagnosis, secondary diagnoses and procedures affecting DRG assignment and profiling outcomes.

Minimum Qualifications

• Minimum Education: Associate’s Degree in Nursing
• Minimum Years of Experience: 3 Years of Clinical Experience in an Acute Care Setting
• Substitutable Education & Experience (Optional): None
• Required Certifications/Licensure: Current RN License to Practice in the State of South Carolina; Currently has certification from ACDIS (Certified Clinical Documentation Specialist - CCDS) or AHMIA (Certified Documentation Improvement Practitioner - CDIP) OR eligible certification must be obtained from one of these entities within 2 years of entry into the role.

Essential Functions

• Collaborates with physician, physician extender, nurse, case manager/utilization reviewer and Medical Records coder to identify principal diagnosis options, secondary diagnoses and procedures, to assign working DRGs for identified populations.
• Identifies need to clarify documentation in records. Utilizes strong communication skills with physician, physician extender, case manager, utilization reviewer, nurse or other healthcare professionals, utilizing appropriate tools to capture needed documentation.
• Able to conduct thorough medical record review on initial and extended-stay concurrent reviews on all selected inpatient admission and documents findings to identify MCCs/CCs, PSI, HAC, mortality second-level review, and patient length of stay that supports patient’s severity of illness and risk of mortality denoting all key information utilized in the tracking process.
• Maintains complete confidentiality of patient information, in addition to hospital and individual physician practice pattern data.
• Able to utilize software, programs, and other technology tools to prioritize and maintain workflow.

Duties & Responsibilities

• Develop and sustain positive working relationships with providers, advanced practice providers, administrators, peers, and other collaborating departments to promote the success of the CDI program.
• Able to effectively prioritize tasks with workflow.
• Stay up to date with industry standards by participating in internal and external continuing education related to ACDIS, ICD-10-CM coding, ICD-10-PCS coding, AHA Coding Clinics, and CMS Official Coding Guidelines.