RN Clinical Documentation Integrity Spec, CDI & ICU exp wanted

Job Summary

This licensed professional nurse (RN) works with the Medical Staff to offer documentation education to ensure an accurate and complete medical record with documentation that allows for codeable diagnosis and/or procedures. He/she works within the scope of the HIM Department to provide documentation that best represents the patient's clinical findings and treatment plan. This professional is also responsible for data quality review on specified records, resolution of DRG/APG/ASC coding changes with third party payers and provides structured education programs. The candidate must be able to follow standard practices in coding/reimbursement and to optimize payment for all financial schemes. He/she must demonstrate exceptional judgment and organizational ability and possess excellent communication skills, both written and oral.

Education Required

• Registered Nurse in the state of TN
• Preferred: BSN

Experience Required

• The candidate must have a strong clinical background (minimum of five years bed side nursing).
• Must be computer literate with experience in Microsoft Office and/or Excel.
• Preferred: The candidate would have an understanding of reimbursement principles and/or coding concepts.

Position Summary

Responsible for communication with the medical staff to improve the quality and clarity of documentation of patients' condition in the medical record. Reduces physician's workload through assistance with regulatory guides through clinical review. Supports documentation of clinically supported procedures. When documentation is incomplete, vague, or ambiguous, it is the responsibility of the CDI nurse to utilize the appropriate physician clarification process to obtain additional information that provides a codeable diagnosis, procedure. Reviews inpatient medical records to assign and sequence all appropriate diagnosis and procedures codes utilizing encoder software and proficiently translating diagnostic statements, physician orders, and other pertinent documentation. Reviews Medicare Severity Diagnosis Related Groups (MSDRGs) and All Patient Refined Diagnosis Related Groups (APRDRGs) on inpatient cases. Reviews appropriate CDI work lanes daily to address coding edits and needed corrections and follows procedure as needed to resolve these cases. Reviews accounts and performs needed correction for internal audits. This position may be assigned 2nd level review cases based on defined department processes. The CDI nurse will review these cases and follow department process for communication on missed findings.

Department Position Summary

• The CDI nurse will review inpatient medical records to assign and sequence all appropriate diagnosis and procedures codes utilizing encoder software and proficiently translating diagnostic statements, physician orders, and other pertinent documentation.
• Reviews Medicare Severity Diagnosis Related Groups (MSDRGs) and All Patient Refined Diagnosis Related Groups (APRDRGs) on inpatient cases.
• Reviews appropriate CDI work lanes daily to address coding edits and needed corrections and follows procedure as needed to resolve these cases.
• Reviews accounts and performs needed correction for internal audits.
• This position may be assigned 2nd level review cases based on defined department processes.
• The CDI nurse will review these cases and follow department process for communication on missed findings.

Other Responsibilities

• Adheres to Health Information Management (HIM) Coding and CDI policies.
• Interprets and applies American Hospital Association (AHA) Official Coding Guidelines to articulate and support appropriate principal, secondary diagnoses and procedures.
• Adheres to Det Norske Veritas (DNV) and other third-party documentation guidelines in an effort to continually improve coding quality and accuracy.
• Responsibility for maintaining knowledge referencing current diagnosis and procedural coding, coding guidelines and regulatory changes.
• Contacts the appropriate department or physician for assistance in obtaining physician clarification of diagnoses.
• Participates in performance improvement initiatives as assigned.
• This position must consistently meet or exceed productivity and quality standards as defined by department Leadership.