RN – Clinical Documentation Improvement Specialist

Baptist Health is the largest healthcare system serving central Alabama, providing comprehensive hospital-based and outpatient services to nearly 60 percent of the residents in Montgomery, Autauga and Elmore counties.

To learn more about Baptist Health, visit us at https://www.baptistfirst.org.

Highlights:

Summary: The RN – Clinical Documentation Improvement (CDI) Specialist is responsible for facilitating the integrity in the overall quality and completeness of provider-based clinical documentation in the medical record. The CDI Specialist assesses clinical documentation through extensive review of the medical record, interaction with physicians, nursing staff, other patient care givers, and Health Information Management (HIM) coding staff to ensure that appropriate reimbursement is received for the level of services rendered to patients and the clinical information utilized in profiling and reporting outcomes is complete and accurate. The goal is to ensure that documentation in the EMR accurately reflects the severity of illness of the patient. This position may have additional duties assigned that are within scope of the role.
Education / Experience:Degree in Nursing, Bachelor’s degree in Nursing preferred. Minimum 3 years coding and reimbursement in acute care setting. Experience with DRG’s preferred.
License / Certification: Active RN license required, Certified Clinical Documentation Specialist (CCDS) preferred
Knowledge, Skills, and Abilities:
• Skill in the use of computers.
• Ability to effectively manage time and schedules.
• Ability to monitor and/or maintain quality control standards.
• Ability to work both independently and in a team environment.
• Knowledge of clinical documentation requirements.
• Knowledge of organizational structure, workflow, and operating procedures.
• Exhibits a sufficient knowledge of clinical documentation requirements, DRG assignment, and clinical conditions or procedures.
• Extensive knowledge of ICD and reimbursement methodologies.

Working Conditions/Physical Requirements:
Position requires sitting for 90% of the workday and mobility 10% of the workday.
There is occasional stooping, bending, kneeling, and crouching.
There is frequent reaching, use of hands and repetitive action.
Requires occasional lifting or carrying up to 25 pounds, pushing/pulling up to 50 pounds.
There is a continuous need for speaking with clear diction and hearing sensitivity in conversation either by phone or in person.
Continuous visual acuity at close and distant range.
Inside protected from weather conditions but not necessarily from temperature changes. Minimal noise levels.
Much exposure to computer work.
Occasional exposure to risk of electrical shock.
Some exposure to infectious disease while performing job-related tasks.
Some exposure to hazardous chemicals. Occasional exposure to radiation.

Primary Location:

Corporate

Job:

RN – Clinical Documentation Improvement Specialist

RN Clinical Documentation Improvement Specialist

Job Type:

Regular-Full time

Shift:

First Shift (United States of America)