CDI Specialist facilitating physician documentation and conducting patient record reviews. Ensuring accuracy and adherence to clinical documentation improvement standards at Ensemble Health Partners.
About the role
- RN Clinical Documentation Improvement Specialist assisting in ensuring accurate patient documentation at Atrium Health Mercy. Collaborating with healthcare team to maintain compliance and quality in medical records.
Responsibilities
- Assists treating providers to ensure documentation in the medical record accurately reflects the severity of illness of the patient as well as the level of service rendered.
- Uses clinical/nursing knowledge and understanding of national coding guidelines and standards of compliance to improve overall quality and completeness of clinical documentation.
- Works collaboratively with physicians and advanced practice providers to ensure the clinical information is accurate, complete, and compliant.
- Educates members of the patient care team regarding documentation guidelines, coding requirements and service specific requirements.
- 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 based upon the clinical evidence documented.
- Ensures that all written requests to physicians for additional documentation support Corporate Compliance policies.
Requirements
- Registered Nurse North Carolina 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
- Ability to speak English fluently and write in understandable terms.
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
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