Registered Nurse Clinical Documentation Integrity Specialist - Inpatient

Summary

Provides concurrent review of the clinical documentation in the medical record; reviews the medical record with a clinical lens to identify any missing or understated diagnoses. Queries the medical staff when necessary, by written and/or verbal communication to obtain accurate and complete physician documentation that supports the patient condition(s) and treatment plan. Performs a thorough chart review to determine the appropriate principal diagnosis of the patient. Coordinates with coding/HIM/UR and other departments to achieve a record that reflects the acuity of the patient and level of care provided.

Essential Functions

• Conducts initial and follow-up concurrent reviews on inpatient admissions for opportunities to clarify documentation in the medical record for accurate reflection of the acuity of the patient and justifying the level of care.
• Documents findings in workflow tools, noting all key information used in the tracking process.
• Reviews medical record concurrently for documentation not yet in the record but supported by clinical indicators.
• Uses relationship building and strong communication skills to develop a rapport with providers to clarify information in the medical record.
• Uses appropriate querying templates to get needed documentation.
• Conducts follow-up on unanswered queries during the patient stay to obtain a response to unanswered queries.
• Provides education to physicians on the importance of complete documentation and key documentation concepts during regular physician meetings or on individually with physicians.
• Uses data provided by managers, directors, and consulting team to identify what is working well and areas of focus.

Minimum Qualifications

• Graduation from a qualified, nationally-accredited nursing program.
• Three (3) years of RN clinical experience in an acute care setting. CDI experience preferred.
• Current RN licensure permitting work in state of Arizona.
• CCDS (Certified Clinical Documentation Specialist) from ACDIS or CDIP ( Certified Documentation Improvement Practitioner) from AHIMA preferred.

Knowledge, Skills And Abilities

• Extensive clinical knowledge and understanding of pathology/physiology; best demonstrated by clinical experience in hospital setting.
• Strong critical thinking skills and the ability to review the medical record to identify information not yet documented but supported by clinical indicators or clinical clues.
• Knowledge of age-specific patient needs and the elements of disease processes and related procedures.
• Excellent written and verbal communication skills; ability to write concisely and effectively when communicating with providers.
• Assertive personality traits to facilitate ongoing physician communication.
• Working knowledge of inpatient admission criteria.
• Ability to work independently in a time-oriented environment.
• Ability to stand and walk in the performance of job responsibilities.
• Demonstrates knowledge of the importance of, and makes an effort to capture, all appropriate secondary diagnoses for quality rating purposes.