Licensed RN with 5+ years of inpatient clinical experience.
CDS or CDIP certification required within two years.
AAS degree required; BSN preferred or willingness to complete within 5 years.
3-5 years of CDI experience is essential.
Leadership experience is preferred.
Responsibilities
Perform extensive medical record reviews using CDI software integrated with EMR.
Facilitate clinical documentation improvement through interaction with physicians and healthcare team members.
Lead the CDI team and coordinate documentation improvement practices.
Oversee training and education for providers and CDI staff.
Participate in team meetings to develop improvement efforts for the Clinical Documentation Management Program.
Benefits
Comprehensive training and education opportunities.
Collaborative work environment with a focus on mentorship.
Access to advanced CDI software and technology.
Opportunities for professional development and certification.
Support for compliance with healthcare regulations.
Full Job Description
Main Function
Performs extensive medical record review through the use of CDI software integrated with the EMR.
Facilitates clinical documentation improvement through concurrent and retrospective interaction with physicians and members of the healthcare team. This interaction supports the clinical severity of the inpatient admission, quality documentation standards that align with federal and state regulations and assists with maximizing revenue and risk stratification.
Act as the lead for the CDI team and assist with coordination of clinical documentation improvement practices consistent with corporate compliance guidelines and appropriate financial reimbursement based on the acuity of the patient population.
Oversee training and education for providers, nurses and other CDI staff.
Actively participate in team and committee meetings to assist with the development of improvement efforts and education regarding the Clinical Documentation Management Program (CDMP)
Required Job Specific Competencies
Advanced Clinical Knowledge: including comprehensive understanding of anatomy, physiology, and disease processes
Expertise in coding and reimbursement methodologies
Clinical documentation principles: a strong grasp of compliant clinical documentation practices
Effective physician querying: ability to formulate clear, concise and non-leading queries to physicians and other providers
Auditing and Quality Assurance: proficiency in conducting retrospective and concurrent review of medical records
Data Analysis and Reporting: ability to analyze CDI program date, identify trends in documentation and measure program effectiveness
Education and training development: skill in developing and delivering targeted education and training programs for physicians, advanced practice providers, residents, and other healthcare staff on documentation best practices
Leadership and mentorship: ability to lead a team of CDI specialists, provide guidance, mentorship and constructive feedback. Foster a collaborative and high-performing work environment
Technology proficiency: competence in utilizing electronic health record systems, CDI software and other relevant healthcare information technology
Adherence to all relevant health care regulations and hospital policies related to patient privacy (HIPAA), documentation, and billing
Qualifications
Licensed RN with minimum of 5 years inpatient clinical experience and extensive knowledge of complex disease processes.
CDS (Clinical Documentation Specialist) or CDIP (Clinical Documentation Improvement Practitioner certification required within two years of starting the role.
Education
AAS required
BSN preferred or willingness to complete within 5 years of hire
Experience
Minimum 3-5 years CDI experience
Leadership experience preferred
Advanced clinical experience with extensive knowledge of complex disease processes preferred
Proficiency with computers, spreadsheets and Microsoft office
