Clinical Documentation Specialist Outpatient
About the role
The Outpatient Clinical Documentation Integrity (CDI) Specialist Nurse will provide clinically based reviews of outpatient medical records to assess and procure accurate, complete, and compliant documentation of the patients’ visit encounter. The goal is to facilitate clinically appropriate physician and other clinician documentation of all patient conditions, treatments, and interventions to accurately reflect quality of care, severity of illness, risk of morality and risk adjustment factor to support correct coding, reimbursement, and quality initiatives.
Responsibilities
- Provide clinically based reviews of outpatient medical records to assess and procure accurate, complete, and compliant documentation of the patients’ visit encounter.
- Facilitate clinically appropriate physician and other clinician documentation of all patient conditions, treatments, and interventions to accurately reflect quality of care, severity of illness, and risk of morality and risk adjustment factor to support correct coding, reimbursement, and quality initiatives.
- Work closely with all levels of leadership, subject matter experts, and operational stakeholders to remain compliant with state and federal regulatory codes and guidelines.
Requirements
- Registered Nurse (RN) preferred
- Current RN or LPN Licensure in the State of Alabama required
- At least five years of nursing experience required (3 of these years must be in acute or intensive care setting), prefer pediatric experience. Will consider CDI experience in lieu of pediatric experience.
- Licensures, Certifications, and/or Registries: CCDS and/or Coding certification (ex. CPC) highly desired or willingness to complete after employment.
Qualifications
- Bachelor of Science Nursing in Nursing or Associate of Science Nursing in Nursing
- 5 Years job experience as Staff Level with specialization in the field of Nursing Acute
Skills
- Strong clinical knowledge
- Excellent communication skills
- Attention to detail
- Ability to work independently and collaboratively
Benefits
Details about benefits will be provided upon hire.
Pay
Details about pay will be provided upon hire.
Schedule
Monday-Friday, Day Shift, Monday-Friday Standard Days
About the Location
Discover what it’s like to live and work in Birmingham, Alabama.