Clinical Documentation Specialist II – RN

Job Description:

• Concurrently reviews inpatient records to ensure completeness, accuracy, and clinical validation.
• Evaluates documentation for assignment of working and possible DRG.
• Recognizes opportunities for documentation improvement, including severity of illness, risk of mortality, core measures, and patient safety/quality.
• Identify opportunities to query physicians regarding missing, unclear, or conflicting documentation.
• Interacts directly with physicians to request and obtain additional documentation when needed.
• Timely follow-up on all unanswered queries based on the query escalation policy.
• Facilitates modifications to physician documentation to reflect the complexity of care of the patient and appropriate reimbursement.
• Maintains a collaborative working relationship with the Health Information Coding staff and serves as a clinical resource.
• Collaborates with and educates members of the patient care team regarding documentation guidelines, including physicians, allied health practitioners, nursing, and case management.
• Performs mortality reviews and optimizes the risk of mortality.
• Maintains review worksheet on all records using CDI software.
• Ensures the accuracy of clinical information used for measuring and reporting physician and hospital quality outcomes.
• Reviews, evaluates, analyzes, and interprets data related to documentation on an ongoing basis.
• Identifies trends or potential problems and assists in developing action plans to address.
• Participates in additional projects such as developing physician education materials, CDI week advertisements, etc.
• Adheres to ethical and professional business practices.
• All other duties as assigned.

Requirements:

• Bachelor’s in Nursing, required
• RN License
• Clinical Documentation Specialist Certification via ACDIS or AHIMA
• 2-5 years of medical/surgical nursing experience in the acute hospital setting
• Experienced Clinical Documentation Specialist with minimum of 2 years recent experience in CDI role
• Critical Care and/or Emergency Nursing experience required
• Proficient skill in query writing to physicians
• Knowledge to accurately complete chart audits
• Organizational and critical thinking skills required
• Experience with computer systems required, including web-based applications and some Microsoft Office applications which may include Outlook, Word, Excel, PowerPoint, or Access

Benefits:

• Comprehensive compensation and benefits
• Support for achieving a healthy and balanced life

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