RN Clinical Documentation Improvement Specialist- Remote

Job Duties

• Performs medical record review on patient admission and throughout the stay for documentation completeness and accuracy in accordance with the Clinical Documentation Program requirements.
• Identifies opportunities for improved physician and hospital outcomes and quality documentation.
• Initiates interaction with providers to obtain clarification of documentation to most accurately represent severity of illness, risk of mortality and acuity and complexity of care.
• Serves as a resource and communicates with providers, case managers, coders, and other healthcare team members to facilitate comprehensive medical record documentation to reflect clinical treatment, decisions, and diagnoses for inpatients.
• Effectively acts as a consultant to coders when additional information or documentation is needed to assign the correct DRG.
• Actively supports and participates in provider/hospital performance improvement initiatives.

Knowledge, Skills and Abilities (KSAs)

• Clinical expertise and knowledge of complex disease processes with a broad clinical experience in an inpatient setting.
• Broad-based clinical knowledge and understanding of pathology/physiology of disease processes.
• Computer skills and dexterity for data entry and retrieval of patient information.
• Effective verbal and written communication skills and ability to present information clearly and professionally to varying levels of individuals throughout the patient care process.
• Proficient with Windows-style applications and various software packages specific to role and keyboard.
• Ability to work a flexible work schedule (e.g. 24/7, weekend, holiday, on call availability).