RN Clinical Documentation Specialist - Referrals
Core
Facilitate and obtain appropriate physician documentation for patient clinical conditions and procedures to support severity of illness, expected risk of mortality, and complexity of care.
Role type
Clinical Documentation Improvement (CDI) Specialist
Builds
Accurate clinical documentation and supporting evidence for medical record reviews and payor appeals
Domain
Healthcare Revenue Cycle Management
Required skills
Acute care nursing experience, Medical record review, Physician interaction, ICD-10-CM coding, DRG assignment, Severity of Illness (SOI) assessment, Risk of Mortality (ROM) assessment, Denial appeal writing, Regulatory guideline compliance
Preferred skills
Experience with Intensive Care or Emergency Department, Openness to AI innovation
Technologies
CDE software, Encoder
Responsibilities
Review patient medical records within 24-48 hours of admission and subsequent reviews; Assign principal diagnosis, CC/MCC, SOI, and ROM; Clarify missing or unclear documentation with physicians; Educate healthcare providers on documentation guidelines; Partner with coding professionals to ensure data accuracy and resolve DRG denials; Formulate and submit timely appeals to third-party administrators.
Seniority
Mid-level, hands-on IC
