Clinical Documentation Integrity Registered Nurse RN- Hybrid

About the role

Birmingham, Alabama Conifer Revenue Cycle Solutions is seeking a Clinical Documentation Integrity Registered Nurse RN- Hybrid to join their team.

Responsibilities

• 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.
• 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.
• Affords assistance 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.
• Affords assistance in training department staff new to CDI.
• Performs other duties as assigned.

Qualifications

• Preferred: Acute Care nursing and/or Provider relevant experience
• Zero (0) to two (2) years CDI experience
• Two (2) plus years’ nursing experience – Medical/Surgical/Intensive Care and/or Case/Utilization Review
• Two (2) plus years’ Provider experience – Medical/Surgical/Intensive Care and/or Case/Utilization Review
• Graduate from a Nursing program, BSN, or graduate program; OR Graduate from Medical Doctor and/or Foreign Medical Doctor Program
• Preferred: CDIP or CCDS

Skills

• 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.

Benefits

Conifer Health offers a competitive benefits package to its employees.

Pay

The pay for this position is commensurate with experience.

Schedule

The schedule for this position is hybrid, combining both in-person and remote work options.