RN - SLR

About the role

The CDI Specialist works towards optimizing reimbursement by following the American Health Information Management Association’s Ethical Standards for Clinical Documentation Professionals. They work extensively with physicians, Advanced Practice Providers, Nursing, HIM Coders, and others to ensure timely and accurate documentation.

Responsibilities

• Concurrently and retrospectively reviews inpatient medical records to identify the most appropriate principal diagnosis and to assign a working DRG.
  • Completes the initial review within 24 hours of admission.
  • Completes concurrent reviews to ensure working DRG and all comorbid conditions are documented by the providers to the greatest specificity.
  • Sends compliant queries to providers for clarification regarding documentation.
  • Reviews one-day stay and second surgical review cases each week.
  • Provides in-person CDI training to providers one-on-one.
  • Affords assistance in other monitoring activities, special department projects, or other needs as determined by the department director.
  • Maintains integrity and compliance in all chart reviews and CDI documentation and queries at all times.
  • Supports and implements quality measures as identified by the department manager.

Requirements

• Education & Experience:
  • Required: ASN or Associate of Science in Health Information Management.
  • PREFERRED: Advanced degrees in Nursing or Health Information Management.
  • Required: 2 or more years of experience working in an acute care setting or ambulatory office setting.
  • PREFERRED: Previous experience in CDI.

Qualifications

• Licensure: Registered Nurse as applicable.
• Certifications: RHIA, RHIT, CCS, Certified Clinical Documentation Specialist (CCDS), OR Certified Documentation Improvement Professional (CDIP), LPN, RN.

Skills

• Strong communication skills.
• Ability to work independently and collaboratively.
• Attention to detail.
• Knowledge of clinical documentation standards and guidelines.

Benefits

N/A

Pay

N/A

Schedule

Day Shift. 40 hours weekly. Monday - Friday, no holidays. Position onsite.