Clinical Documentation Improvement Specialist - RN

Deaconess Health System • Evansville, IN

1d • Onsite

About The Position

Day-to-day our Clinical Documentation Improvement Specialists are primarily responsible for evaluating concurrent documentation so that the medical record appropriately reflects the severity and risk of the patient’s conditions. Under the supervision of the CDI Leadership, CDI Specialists will conduct review of medical records to identify missing, vague and or incomplete diagnosis; communicate the need for additional documentation to the appropriate medial and clinical staff; ensure the additional documentation is completed in a timely manner; work collaboratively with other departments including Coding, Quality, Compliance, Medical Staff, Utilization Review/Case Management, Medical Records and any other applicable departments to improve the quality of physician documentation. This roles supports initiatives to improve the quality of documentation by all caregivers.

Requirements

• Active Registered Nurse (RN) in Indiana, Illinois and Kentucky or a compact licensed state
• Minimum of five (5) years of related adult, acute clinical experience required

Nice To Haves

• Bachelor's Degree in Nursing (BSN)
• ACDIS certification preferred

Responsibilities

• Evaluating concurrent documentation so that the medical record appropriately reflects the severity and risk of the patient’s conditions.
• Conducting review of medical records to identify missing, vague and or incomplete diagnosis.
• Communicating the need for additional documentation to the appropriate medial and clinical staff.
• Ensuring the additional documentation is completed in a timely manner.
• Working collaboratively with other departments including Coding, Quality, Compliance, Medical Staff, Utilization Review/Case Management, Medical Records and any other applicable departments to improve the quality of physician documentation.
• Supporting initiatives to improve the quality of documentation by all caregivers.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: No Education Listed