RN Clinical Documentation Specialist-Full Time

About the role

The Clinical Documentation Integrity Specialist I (CDI) uses independent clinical judgement to ensure the integrity, quality, accuracy, and completeness of provider-based clinical documentation in the medical record. This role collaborates with healthcare providers to ensure documentation accurately reflects the severity of illness and risk of mortality of the patient.

The CDI Specialist assesses clinical documentation through extensive medical record reviews, interactions with healthcare team members, and collaboration with the Healthcare Information Management (HIM) Coding team. This ensures appropriate coding, Diagnosis Related Group (DRG) assignment, and accurate profiling and reporting of outcomes.

Responsibilities

• Determine working Diagnosis Related Group (DRG) assignment and apply clinical expertise to identify opportunities for improved or clarified documentation that accurately reflects the severity of illness (SOI) and risk of mortality (ROM).
• Follow up directly and timely with clinical providers to ensure requested clarification is provided.
• Develop clinical documentation integrity (CDI) skills, including research, technology, and treatment modalities.
• Utilize critical thinking and problem-solving in the chart review process to determine diagnoses and procedures.
• Use professional association resources and regulatory agency guidelines (e.g., Coding Clinics, AHIMA, ACDIS, CMS) to enhance skill sets.
• Learn to write concurrent and retrospective queries for clarification of medical record information necessary for appropriate assignment of diagnoses and procedures.
• Establish and reconcile DRG processes compliant with departmental guidelines and CMS regulations.
• Reconcile cases in the CDI database 80% of the time, as determined by quality audit after training.
• Collaborate with the CDI manager, educator, and team preceptors to learn proper reviewing procedures, selection of primary and secondary diagnoses, and the impact of accurate documentation on the revenue cycle.
• Apply knowledge of healthcare workflows to work collaboratively with medical staff and other team members to improve the accuracy and comprehensiveness of medical record documentation, focusing on accurate reporting of quality outcomes.
• Learn the impact of accurate clinical documentation in establishing the primary diagnosis.
• Meet established operational and productivity standards.
• Learn to use the CDI business platform (e.g., 3M, PowerChart, Cerner).
• Perform other duties as assigned.
• Maintain compliance with Centra Health policies and procedures, including vaccinations.
• Expand own nursing and CDI knowledge and maintain registered nurse licensure.

Requirements

• Registered Nurse in the State of Virginia or a compact state.
• 5+ years of clinical nursing experience, preferably in an intensive clinical nursing environment.
• Excellent computer skills.
• Must pass a prequalification CDI Specialist test with a minimum score of 85%.

Qualifications

Preferred:

• ACDIS CDI Apprenticeship Certification.

Skills

• Thorough clinical skills, including working knowledge of pathology, pharmacology, and surgical procedures.
• Excellent written and verbal communication skills.
• Ability to function independently and as a team player in a fast-paced environment.
• Detail-oriented with strong relationship-building skills.
• Extensive knowledge of disease pathophysiology.
• Proficiency with PCs, Microsoft Office suite, and general office equipment (e.g., printers, copy machines, fax machines).

Pay

$34.59–$50.15 per hour.

Schedule

• Monday through Friday, 40-hour work week.
• Sedentary work: Exerting up to 10 pounds of force occasionally and/or negligible force frequently.
• Primarily remote office setting, with occasional travel (0%–10% of the time).

Work Environment

• Moderate noise level in the work environment.
• No routine exposure to blood, body fluids, or tissues.
• Regular communication with others; frequent standing, walking, sitting, and use of hands.
• Occasional climbing, balancing, stooping, kneeling, crouching, or crawling.
• Use of Centra Health CDI Specialist computer equipment.