[Hiring] Clinical Documentation Specialist III-Registered Nurse-Labor Pool-Days @Riverside Health System

Role Description This position is remote work eligible for candidates residing in the following states: FL, GA, ID, KS, KY, MS, NC, OK, SC, SD, TN, VA. *Some county exclusions may apply.

• Facilitates the overall quality and completeness of provider-based clinical documentation in the medical record.
• Provides a thorough clinical review of the medical record to provide an accurate picture of the patient including severity of illness, risk of mortality and resource utilization.
• Serves as a subject matter expert in clinical documentation.

What you will do

• Assesses clinical documentation through extensive review of the medical record.
• Interacts with providers, nursing staff, other patient care givers, and coding staff to ensure appropriate reimbursement is received for services rendered.
• Conducts post discharge reconciliation for comparative analysis of CDI specialist and final coding MS/APR DRG.
• Formulates appropriate clinical documentation clarifications to improve documentation of principal diagnosis, comorbidities, present on admission (POA), hospital acquired conditions (HAC) and patient safety indicators (PSI).
• Queries providers and APP's to clarify documentation in the EMR.
• The CDI nurse will maintain a query rate of at least 20% with a productivity rate average of 20 reviews per day (including new and follow up cases).
• Works with providers and Advanced Practitioners (APP) to improve provider's clinical documentation.
• Participates in departmental education, training and orientation sessions for the team.
• Assists in precepting new CDI nurses when needed.
• Assists in overall quality, timeliness and completeness of the quality health record.
• Collaborates with healthcare team to ensure physician queries are resolved prior to discharge.
• Analyzes clinical information to identify areas within the chart for potential gaps in physician documentation.
• Identifies ongoing documentation improvement opportunities.
• Creates and manages review process and support tools.
• Upholds the Standards of Conduct and Corporate Compliance.
• Supports and assists the Quality department.
• Acts as consultant to coding professionals when additional information or documentation is needed.
• Reviews clinical issues with coding staff to assign a working DRG and/or clarification of documentation.
• Demonstrates initiative to improve quality and customer service.
• Institutes coaching sessions or corrective action plans as necessary.
• Proactively develops a reciprocal relationship with the Coding Professionals.
• Performs patient chart reviews during absences and when coverage is necessary.
• Queries providers and APP's to clarify documentation in the EMR.
• Precepts new CDI nurses and serves as a subject matter expert for CDI.
• Participates and provides input regarding CDI program activities.
• Composes and initiates AHIMA compliant queries.
• Maintains personal and professional education and growth.
• Other duties as assigned.

Qualifications

• Associates Degree, Nursing (Required)
• Bachelors Degree, Nursing or healthcare related (Preferred)
• 5-6 years Nursing experience, preferred pt care, critical care, utilization management, quality, or patient navigator (Required)
• 3-4 years CDI experience (Required)

Requirements

• Knowledge of ICD-10 and coding rules and regulations.
• Experience with 3M 360 or other encoder.
• Strong verbal communication skills.
• Knowledge of basic nursing principles and protocols.
• Proficient in clinical practice protocols for medical procedures and patient care.
• Time management and decision making skills.
• Excellent organizational skills with an attention to detail.
• Understanding the implications of new information for problem-solving and decision-making.
• Utilize extensive understanding of documentation requirements and guidelines.
• Familiarity with the organization of medical records, medical terminology, and disease process.
• Ability to work effectively as team members with physicians and other staff.
• Ability to sit for extended periods of time.
• Able to establish good customer relationships with trust and respect.
• Strong clinical assessment and critical thinking skills.

Licenses and Certifications

• Registered Nurse (RN) - State Department of Health Professions Upon Hire (Required)
• Certified Documentation Integrity Practitioner (CDIP) - The American Health Information Management Association (AHIMA) Upon Hire (Required)
• Certified Clinical Document Specialist (CD) - Association of Clinical Documentation Integrity Specialists (ACDIS) Upon Hire (Required)
• Certified Coding Specialist (CCS) - The American Health Information Management Association (AHIMA) (Preferred)
• Registered Health Information Administrator (RHIA) - The American Health Information Management Association (AHIMA) (Preferred)
• Registered Health Information Technician (RHIT) - The American Health Information Management Association (AHIMA) (Preferred)

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