CDI Nurse

Position: CDI Nurse

Location: 100% Remote

Duration: 6 month Contract-To-Hire

Start Date: ASAP

Job Description:

The Clinical Documentation Improvement Specialist uses clinical and coding knowledge for conducting clinically based concurrent and retrospective reviews of inpatient medical records to evaluate the clinical documentation of clinical services by identifying opportunities for improving the quality of medical record documentation, including focused reviews in areas identified by CDI leadership: Mortality reviews, PSI reviews, as well as other identified projects. Facilitates and obtains appropriate physician documentation for any clinical conditions or procedures to support the appropriate severity of illness, expected risk of mortality and complexity of care of the patient. Participates in ongoing documentation improvement initiatives, including formal and informal education plans related to clinical documentation improvement to providers and the CDI team. Assist with onboarding and training new CDI team members.

Essential Functions

The essential functions listed are typical examples of work performed by positions in this job classification. They are not designed to contain or be interpreted as a comprehensive inventory of all duties, tasks, and responsibilities. Employees may also perform other duties as assigned.

• Employees must abide by all Joint Commission Requirements including but not limited to sensitivity to cultural diversity, patient care, patients’ rights and ethical treatment, safety and security of physical environments, emergency management, teamwork, respect for others, participation in ongoing education and training, communication and adherence to safety and quality programs, sustaining compliance with National Patient Safety Goals, and licensure and health screenings.
• Employees must perform all duties and responsibilities in accordance with hospital programs.
• Reviews clinical documentation to facilitate the accurate representation of the severity of illness, expected risk of mortality, and complexity of care by improving the quality of the physician’s clinical documentation.
• Communicates review results to department leadership, CDI Specialists and other appropriate staff. Makes recommendations to R1 leadership for corrective action.
• Conducts focused reviews in areas identified by CDI leadership: Mortality reviews, PSI reviews, as well as other identified projects.
• Develops and presents CDI specialists and other related departments ongoing education on current documentation trends, CDI practices, focus areas and areas of opportunity identified through the analysis of the clinical and documentation information from a variety of internal and external sources. Lead new CDI specialist orientation.
• Serves as a subject matter expert and authoritative resource on interpretation and application of CDI practices, coding rules and regulations and conducts risk assessments of potential and detected compliance deficiencies, as well as documentation improvement opportunities.
• Utilizes Hospital coding code set, policies and procedures, Federal and State coding reimbursement guidelines, and application of the Coding Clinic Guidelines to assign working DRG, reviewing patient records throughout hospitalization that have been identified as focus DRG by regulatory agencies or the facility to ensure the codes are reported at the highest specificity.
• Initiates physician interaction when ambiguous, missing or conflicting information is in the medical record, through the physician query process and/or participation in rounding with the physicians by requesting additional documentation for correct coding and compliance necessary for accurate reflection of CMI, LOS, and optimal resource utilization.
• Partners with the HIMS coding staff to ensure accuracy of diagnostic and procedural data and completeness of supporting documentation to determine a working and final DRG, severity of illness, risk of mortality and quality outcomes.
• Leads provider engagement, relationship establishment and maintenance related to CDI and documentation improvement efforts.
• Leads and manages ongoing documentation improvement initiatives, including formal and informal education plans related to clinical documentation improvement.
• Leads and/or participates in department and organization projects related to documentation improvement.

Minimum Requirements:

Any combination of education and experience that would likely provide the required knowledge, skills and abilities as well as possession of any required licenses or certifications is qualifying.

Education:

Preferred Bachelor’s degree in a work-related discipline/field (such as Nursing, Biology, Human Anatomy, Microbiology, Health Sciences or similarly related) from an accredited college or university.

Experience:

• 3-5 years of CDI experience
• License/Certifications: Currently holds and maintain at least 1 role-related certification (CCDS, or CCS, or CDIP, or CRCR, or CPHQ, or RN; 2 or more preferred).