ICU Clinical Documentation Integrity Registered Nurse RN- Hybrid

About the role

HYBRID ROLE
MUST LIVE WITHIN 1 HOUR OF BIRMINGHAM, AL

Responsibilities

• Record Review:
  • 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.
• CDI
  • 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.
  • Assists with Provider education, rounding and communication regarding open queries for resolution.
• Professional Development: 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 requires its candidates, as applicable and as permitted by law, to obtain and provide confirmation of all required vaccinations and screenings prior to the start of employment. This may include, but is not limited to, the COVID-19 vaccination, influenza vaccination, and/or any future required vaccines and screenings.

Pay

Commensurate with experience

Schedule

N/A