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 reviewing medical records and collaborating with healthcare teams. Advocate Health provides care across multiple states, ensuring quality documentation and compliance.
Responsibilities
- 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
- 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
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
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