Hybrid Clinical Documentation Improvement Specialist

Posted 7 hours ago

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About the role

  • Reviews selected populations of inpatient medical records to identify the principal and/or secondary diagnoses
  • Appropriately assigns the MS-DRG that most accurately reflects the severity of illness of the patient based upon the clinical evidence documented at the time of the record review
  • Demonstrates knowledge and understanding of severity based DRG systems; All Patient Refined and Medicare Severity (AP-DRG) and Medical Severity Diagnostic Related Group System (MS-DRG)
  • Demonstrates the ability to utilize the licensed software tool to perform and record daily medical record reviews
  • Interacts with the physician and/or other designated members of the healthcare team to ensure that vague or incomplete documentation is clarified within the medical record in a timely manner
  • Works with other departments such as coding, corporate compliance, quality, and finance to support Corporate Goals
  • Participates in the ongoing education of physicians, nurse practitioners, physician assistants and other healthcare team members to identify medical record documentation improvement opportunities employing conflict resolution skills as necessary
  • Utilizes critical thinking skills based upon extensive knowledge of disease processes and clinical outcomes to identify the need for further clarification of physician documentation within the medical record
  • Ensures that all written requests to physicians for additional documentation support Corporate Compliance policies

Requirements

  • Registered Nurse applicable state Licensure required
  • Bachelor's Degree Required
  • Appropriate professional certification required within 3 years of hire date per department protocol
  • 5 years of related nursing experience preferred
  • Clinical experience within the assigned population
  • Extensive knowledge of disease processes and clinical outcomes
  • Case Management experience or background helpful
  • Strong financial and analytical skills preferred
  • Word, Outlook, Excel experience preferred

Benefits

  • Paid Time Off programs
  • Health and welfare benefits such as medical, dental, vision, life, and Short- and Long-Term Disability
  • Flexible Spending Accounts for eligible health care and dependent care expenses
  • Family benefits such as adoption assistance and paid parental leave
  • Defined contribution retirement plans with employer match and other financial wellness programs
  • Educational Assistance Program

Job title

Clinical Documentation Improvement Specialist

Job type

Experience level

Mid levelSenior

Salary

$37,500 - $56,250 per year

Degree requirement

Bachelor's Degree

Location requirements

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