CDQI Nurse Specialist - PRN

About the role

The Clinical Documentation Quality Improvement (CDQI) Specialist plays a pivotal role in enhancing the clarity, completeness, and overall quality of medical record documentation. This position ensures accurate and comprehensive physician documentation, which directly impacts the precision of code assignment and the accuracy of healthcare data.

Responsibilities

• Conduct timely, accurate, and complete documentation reviews for selected inpatient records, addressing inadequate or conflicting documentation.
• Collaborate with physicians and caregivers to ensure appropriate reimbursement and clinical severity for DRG-based payer patients.
• Demonstrate understanding of complications, co-morbidities, severity of illness, risk of mortality, case mix index, secondary diagnoses, and procedure impact on DRG.
• Improve coding specificity by educating physicians and caregivers on the importance of clear documentation throughout a patient's stay.
• Follow AHA guidelines and coding clinics for accurate coding and required documentation to ensure compliance.
• Query physicians regarding missing, unclear, or conflicting health record documentation to obtain necessary details.
• Maintain daily production logs for evaluation, tracking cases reviewed, queries placed/responded, etc.
• Perform follow-up reviews to confirm recorded points of clarification in the patient's medical record.
• Ensure confidentiality of all files, documents, and records.
• Meet or exceed production and quality metrics.

Requirements

• 3+ years of CDI experience
• 3+ years of clinical experience in an academic medical center
• Registered Nurse license, Bachelor's degree in Nursing
• CCDS or CDIP certification required
• Must pass a CDI skills competency assessment

Qualifications

• Must be able to accommodate a minimum of 15 hours per week

Skills

• Strong attention to detail
• Excellent communication and interpersonal skills
• Knowledge of medical terminology and coding systems
• Ability to work independently and as part of a team

Benefits

Join a driven and highly collaborative team passionate about creating transformative change in healthcare. Benefits may vary based on location.

Pay

Pay ranges for this job title may differ based on location, responsibilities, skills, experience, and other requirements of the role. The estimated base pay range per hour for this role is: $40—$45 USD.

Schedule

Hours may vary based on client needs.