ACDIS Certified Clinical Documentation Improvement Specialist (CDI) RN

ACDIS Certified Clinical Documentation Improvement Specialist (CDI) RN

Rancho Santa Fe, CA $90,299 - $114,005 a year

Full Time

Position Overview

This role focuses on enhancing the accuracy and completeness of clinical documentation through concurrent review of medical records. The specialist collaborates closely with physicians, nurses, coders, and other healthcare professionals to ensure the patient's clinical picture and treatment details are thoroughly and accurately documented. Acting as a liaison between case management and coding teams, this position plays a vital role in improving documentation quality and supporting appropriate reimbursement.

Key Responsibilities

• Clinical Documentation Improvement:
  • Review medical records for completeness and clarity, identifying missing or ambiguous information related to diagnoses, treatments, and care plans.
  • Analyze documentation to validate diagnoses and ensure accurate assignment of Diagnostic Related Groups (DRG), severity of illness, risk of mortality, and case mix data.
  • Engage with healthcare providers to clarify documentation gaps in an ethical and compliant manner.
  • Track insurance queries to facilitate accurate reimbursement for services rendered.
  • Develop and maintain policies and procedures related to documentation queries, education, and performance metrics.
  • Prepare reports and analyze data to support quality improvement initiatives.
  • Maintain a high accuracy rate in concurrent reviews of assigned patient populations.
• Safety and Compliance:
  • Ensure a safe and clean work environment by adhering to infection control and institutional policies.
  • Monitor records for regulatory compliance, including HIPAA, to prevent fraud and reduce insurance denials.
  • Comply with standards set by regulatory bodies such as The Joint Commission and OSHA.
  • Identify and report any safety concerns promptly.
• Professional Development and Leadership:
  • Provide ongoing education and training to clinical staff on documentation best practices and coding criteria.
  • Participate in meetings, development activities, and in-service training sessions.
  • Analyze trends to recommend improvements in clinical documentation processes.
  • Design and implement education plans for physicians, nurses, and clinical staff to enhance documentation accuracy.
  • Mentor new graduate nurses and students, supporting their professional growth.

Qualifications

• Minimum of five years of experience as a Registered Nurse, including at least three years in utilization management or six months in clinical documentation improvement.

Competencies

• Technical Skills: Proficiency with computer applications such as Word; knowledge of payer types; understanding of ICD-10-CM coding, risk adjustment models, and Hierarchical Condition Category Coding (HCC); expertise in clinical care and coding guidelines; experience with referral management systems preferred.
• Critical Thinking: Detail-oriented with strong prioritization skills; self-motivated and independent thinker.
• Communication: Excellent teamwork, analytical, leadership, and communication skills; ability to educate and collaborate effectively with diverse clinical teams.

Education

• Associate Degree in Nursing required.

Licenses

• Current Registered Nurse license in California required.

Certifications

• Certification in Clinical Documentation Improvement through the Association of Clinical Documentation Improvement Specialists (ACDIS) required within 18 months of hire or transfer.
• Preferred certifications include Registered Health Information Administrator (RHIA), Registered Health Information Technologist (RHIT), Certified Coding Specialist (CCS), Accredited Case Manager (ACM), or Certified Case Manager (CCM).

All candidates must successfully complete a physical evaluation, drug screening, and background checks prior to employment.

This opportunity is located in a vibrant regional area of the United States, serving diverse communities with a commitment to quality and compassionate healthcare.

MLee Healthcare Staffing and Recruiting, Inc