Registered Nurse - Clinical Documentation Integrity Specialist

Responsibilities

• Act as the Registered Nurse Advisor for the facility's CDI program, focusing on both inpatient and outpatient services
• Review health records concurrently to identify opportunities for improved documentation and coding accuracy using clinical knowledge and critical thinking skills
• Support CDI activities by applying the nursing process to data gathered by the CDI team, reviewing it for clinical validation, trends, and opportunities for improvement
• Communicate findings to the CDI team, providers, and other departments as appropriate
• Collaborate with healthcare providers through written, verbal, or electronic clarification requests or queries
• Develop and implement the facility's CDI management program, including charter, Standard Operating Procedures (SOW), workflow, and turnaround time compliance
• Focus on updating problem lists or Scientific Nomenclature of Medicine – Clinical Terminologies (SNOMED-CT) consistent with ICD-10 CM code sets
• Conduct concurrent or retrospective reviews of health records to clarify clinical questions and identify potential query opportunities
• Develop and deliver active training/education programs for clinical staff about current documentation standards and improving techniques
• Provide self-directed support to clinical staff, patients, and families throughout the continuum of care
• Generate weekly, bi-monthly, and monthly reports as required by the COR
• Maintain performance metrics in accordance with VHA requirements
• Participate in collaborative meetings and CDI-specific program initiatives

Qualifications

• Bachelor's degree in Nursing from an accredited program
• Current, full, active and unrestricted RN license in any State, Territory, or Commonwealth of the United States
• Minimum of two years' experience working as a CDI specialist in a hospital setting
• Certification from American Health Information Management Association (AHIMA) and/or American Academy of Professional Coders (AAPC) and/or Association of Clinical Documentation Integrity Specialists (ACDIS)
• Knowledge of ICD-10-CM and MS-DRG coding systems
• Experience with electronic health record systems, particularly VistA/CPRS preferred
• Thorough understanding of medical terminology, anatomy, physiology, disease processes, and treatment protocols
• Knowledge of regulatory guidelines including The Joint Commission, CMS, and VHA requirements
• Excellent communication, interpersonal, and critical thinking skills