RN - SLR

RN - Clinical Documentation Integrity

Follows the American Health Information Management Association's Ethical Standards for Clinical Documentation Professionals. The CDI Specialist works towards optimizing reimbursement. Optimization is the process of striving to obtain the highest possible payment to which the facility is legally entitled on the basis of coded data supported by documentation in the health record. The CDI Specialist works extensively with physicians, Advanced Practice Providers, Nursing, HIM Coders, and others to ensure timely and accurate documentation.

Overview of Responsibilities

• Concurrently and retrospectively reviews inpatient medical records to identify the most appropriate principal diagnosis and to assign a working DRG.
• Completes the initial review within 24 hours of admission.
• Completes concurrent reviews to ensure working DRG and all comorbid conditions are documented by the providers to the greatest specificity. Ensures documentation supports diagnoses.
• Collaborates with the coding staff concurrently and retrospectively to ensure the chart has all the necessary documentation to support the most accurate coding.
• Ensures the medical record reflects the patient's severity of illness and risk of mortality.
• Sends compliant queries to providers for clarification regarding documentation.
• Reviews one-day stay and second surgical review cases each week.
• Provides in-person CDI training to providers one-on-one.
• Assists in other monitoring activities, special department projects, or other needs as determined by the department director.
• Provides ongoing CDS team learning opportunities through sharing of professional knowledge and journal articles.
• Maintains integrity and compliance in all chart reviews and CDI documentation and queries at all times.
• CDS will support and implement quality measures as identified by the department manager.

This list of duties and responsibilities is not intended to be all-inclusive and can be expanded to include other duties or responsibilities that management deems necessary.

Education & Experience

• Education Required: ASN or Associate of Science in Health Information Management.
• Education Preferred: Advanced degrees in Nursing or Health Information Management.
• Experience Required: 2 or more years of experience working in an acute care setting or ambulatory office setting.
• Experience Preferred: Previous experience in CDI.

Licensure & Certification

• Licensure: Registered Nurse as applicable.
• Certifications: RHIA, RHIT, CCS, Certified Clinical Documentation Specialist (CCDS), OR Certified Documentation Improvement Professional (CDIP), LPN, RN.