Clinical Documentation Improvement Specialist - RN
About The Position
Clinical Documentation Improvement Specialists evaluate concurrent documentation to ensure the medical record appropriately reflects the severity and risk of patients’ conditions. Under the supervision of CDI Leadership, the specialist reviews medical records to identify missing, vague, or incomplete diagnoses; communicates the need for additional documentation to appropriate medical and clinical staff; and ensures the additional documentation is completed in a timely manner. The role collaborates with Coding, Quality, Compliance, Medical Staff, Utilization Review/Case Management, Medical Records, and other applicable departments to improve physician documentation. The role supports initiatives to improve documentation quality across all caregivers.
Requirements
- Active Registered Nurse (RN) license in Indiana, Illinois, and Kentucky, or a compact licensed state.
- At least five years of related adult acute clinical experience.
Nice To Haves
- Bachelor’s Degree in Nursing (BSN).
- ACDIS certification.
Responsibilities
- Review medical records concurrently to identify missing, vague, or incomplete diagnoses.
- Communicate the need for additional documentation to appropriate medical and clinical staff.
- Ensure requested additional documentation is completed in a timely manner.
- Collaborate with Coding, Quality, Compliance, Medical Staff, Utilization Review/Case Management, Medical Records, and other applicable departments to improve physician documentation.
- Support initiatives to improve documentation quality across all caregivers.
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What This Job Offers
Job Type
Full-time
Education Level
No Education Listed
