Clinical Documentation Specialist II – RN
Job Description:
- Concurrently reviews inpatient records to ensure completeness, accuracy, and clinical validation.
- Evaluates documentation for assignment of working and possible DRG.
- Recognizes opportunities for documentation improvement, including severity of illness, risk of mortality, core measures, and patient safety/quality.
- Identify opportunities to query physicians regarding missing, unclear, or conflicting documentation.
- Interacts directly with physicians to request and obtain additional documentation when needed.
- Timely follow-up on all unanswered queries based on the query escalation policy.
- Facilitates modifications to physician documentation to reflect the complexity of care of the patient and appropriate reimbursement.
- Maintains a collaborative working relationship with the Health Information Coding staff and serves as a clinical resource.
- Collaborates with and educates members of the patient care team regarding documentation guidelines, including physicians, allied health practitioners, nursing, and case management.
- Performs mortality reviews and optimizes the risk of mortality.
- Maintains review worksheet on all records using CDI software.
- Ensures the accuracy of clinical information used for measuring and reporting physician and hospital quality outcomes.
- Reviews, evaluates, analyzes, and interprets data related to documentation on an ongoing basis.
- Identifies trends or potential problems and assists in developing action plans to address.
- Participates in additional projects such as developing physician education materials, CDI week advertisements, etc.
- Adheres to ethical and professional business practices.
- All other duties as assigned.
Requirements:
- Bachelor’s in Nursing, required
- RN License
- Clinical Documentation Specialist Certification via ACDIS or AHIMA
- 2-5 years of medical/surgical nursing experience in the acute hospital setting
- Experienced Clinical Documentation Specialist with minimum of 2 years recent experience in CDI role
- Critical Care and/or Emergency Nursing experience required
- Proficient skill in query writing to physicians
- Knowledge to accurately complete chart audits
- Organizational and critical thinking skills required
- Experience with computer systems required, including web-based applications and some Microsoft Office applications which may include Outlook, Word, Excel, PowerPoint, or Access
Benefits:
- Comprehensive compensation and benefits
- Support for achieving a healthy and balanced life
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