Clinical Documentation Integrity Specialist- RN- Remote

Job Description

Completes initial reviews of patient records within 24-48 hours of admission
Evaluate documentation to assign the principal diagnosis, pertinent secondary diagnoses, and procedures for accurate DRG assignment, risk of morality, and severity of illness.
Track review details in 3M software.
Conducts follow-up reviews of patients every 2 days to support and assign a working DRG assignment.
Queries physicians regarding missing, unclear, or conflicting medical record documentation by requesting and obtaining additional documentation within the medical record when needed.
Educates physicians and key healthcare providers regarding clinical documentation improvement and the need for accurate and complete documentation in the medical record.
Collaborates with the CDI Manager & Physician Advisor and other ancillary staff regarding interaction with physicians on documentation and to resolve physician queries prior to patient discharge.
Collaborates with the patient care team to ensure accurate documentation in the medical record.

• Edifies new clinical staff regarding documentation requirements as required.
• Maintains confidentiality of all customer/hospital information.
• Exhibits working knowledge of inpatient coding guidelines.
• Adheres to CDI convention and department policies and procedures.
• Investigates, evaluates, and identifies opportunities for improvement and recognizes their relative significance in the overall system.

Essential Duties & Responsibilities

• Works in partnership with an interdisciplinary team to foster collaboration, learning, and accurate and complete medical record documentation.
• Applies diplomacy and professionalism when interacting with physicians and clinicians, especially when addressing missing or conflicting medical record information.
• Keeps current with CDI concepts and practices through conferences, reference material, and review of current literature.

Education

• Minimum Qualifications: Associate’s degree required. Bachelor's degree preferred.
• Licensure, Certification & Registration: RN license required.

Experience

• Experience: 3-5 years of related work experience required in a clinical nursing practice, which includes medical, surgical, and/or ICU background.

Skills, Knowledge & Abilities

• Experience with computer systems required, including web-based applications and some Microsoft Office applications which may include Outlook, Word, Excel, PowerPoint, or Access.
• Preferred Qualifications & Skills: BS in Nursing with 5-8 years of acute care clinical experience. Certified Clinical Documentation Specialist (CCDS) or Certified Clinical Documentation Improvement Professional (CDIP) experience with DRG Reimbursement and ICD-10 Coding.

Pay Range

$76,960.00 USD - $103,578.00 USD

The pay range listed for this position is the annual base salary range the organization reasonably and in good faith expects to pay for this position at this time. Actual compensation is determined based on several factors, that may include seniority, education, training, relevant experience, relevant certifications, geography of work location, job responsibilities, or other applicable factors permissible by law.