RN Nurse Clinical Documentation Improvement Specialist
Core
Conduct clinically based concurrent and retrospective reviews of inpatient medical records to improve documentation quality, severity of illness, and risk of mortality.
Role type
RN Clinical Documentation Improvement (CDI) Specialist
Builds
Accurate medical record documentation supporting appropriate severity of illness and risk of mortality for hospital reimbursement
Domain
Healthcare / Revenue Cycle Management / Clinical Coding
Required skills
Active US RN license, Front line CDI experience in acute care, ICU/Med surge/Telemetry/ED experience, Physician query process, DRG assignment, CMS regulations knowledge, EMR/CDI platforms
Preferred skills
Bachelor's Degree in Nursing, Experience with mortality reviews and PSI reviews
Technologies
EMR platforms, CDI platforms, Hospital coding code sets
Responsibilities
Initiate physician interactions via query process for ambiguous or missing documentation, Educate physicians on documentation requirements and coding guidelines, Collaborate with coders and auditors to resolve documentation issues, Conduct focused reviews on mortality and PSI projects, Stay updated on clinical documentation standards and regulatory changes
Seniority
Mid-level, hands-on IC
