Clinical Documentation Improvement Specialist
About The Position
R1 is the leading provider of technology-driven solutions that transform the patient experience and financial performance of hospitals, health systems, and medical groups. We are the one company that combines the deep expertise of a global workforce of revenue cycle professionals with the industry’s most advanced technology platform, encompassing sophisticated analytics, AI, intelligent automation, and workflow orchestration. As our Clinical Documentation Improvement (CDI) Specialist, you will use clinical and coding knowledge for conducting clinically based concurrent and retrospective reviews of inpatient medical records. Every day, you will evaluate the documentation of clinical services by identifying opportunities for improving the quality of medical record documentation, including focused reviews in areas identified by CDI leadership: Mortality reviews, PSI reviews, and other identified projects. Facilitates and obtains appropriate physician documentation for any clinical conditions or procedures to support the appropriate severity of illness, expected risk of mortality, and complexity of care of the patient. Participates in ongoing documentation improvement initiatives, including formal and informal education plans related to clinical documentation improvement to providers and the CDI team.
Requirements
- Highly skilled in CDI practices, coding, and documentation requirements related to quality outcomes, evaluation of medical record data for accuracy and reimbursement.
- Self-motivated to stay abreast of CMS rules and regulations and incorporate those changes into daily practice.
- Possess flexibility to work in a fast-paced and dynamic environment.
- Ability and willingness to learn other applications such as electronic calendar, MS Teams, MS SharePoint, One Drive, CDE One, and other CDI platforms.
- Effective interpersonal skills.
- Takes initiative, works independently, is self-directed, and highly motivated in work areas.
- Ability to resolve moderate to high complexity issues.
- Basic computer skills to include Word, Excel, PowerPoint, and Outlook/email.
- Ability to effectively provide and receive feedback, both positive and constructive.
- Excellent judgment and self-motivation, experience working independently with minimal supervision.
- Demonstrated judgment, critical thinking, and independent decision-making.
- Associate’s Degree in Nursing (Bachelor’s Degree in Nursing is preferred).
- Three to five years of recent clinical work experience in the medical-surgical area, ICU, telemetry, and or emergency department.
- An active US RN license is required.
- Knowledge or experience in electronic medical records (EMR) platforms and CDI platforms.
Nice To Haves
- Bachelor’s Degree in Nursing
Responsibilities
- Conducts clinically based concurrent and retrospective reviews of inpatient medical records.
- Evaluates the documentation of clinical services by identifying opportunities for improving the quality of medical record documentation.
- Conducts focused reviews in areas identified by CDI leadership: Mortality reviews, PSI reviews, and other identified projects.
- Facilitates and obtains appropriate physician documentation for any clinical conditions or procedures to support the appropriate severity of illness, expected risk of mortality, and complexity of care of the patient.
- Participates in ongoing documentation improvement initiatives, including formal and informal education plans related to clinical documentation improvement to providers and the CDI team.
- Initiates physician interaction when ambiguous, missing, or conflicting information is in the medical record, through the physician query process and/or participation in rounding with the physicians by requesting additional documentation for correct coding and compliance necessary for accurate reflection of CMI, LOS, and optimal resource utilization.
- Educates physicians and other staff on documentation requirements, coding guidelines, and reimbursement policies.
- Utilizes Hospital coding code set, policies and procedures, Federal and State coding reimbursement guidelines, and application of the Coding Clinic Guidelines to assign working DRG, reviewing patient records throughout hospitalization that have been identified as focus DRG by regulatory agencies or the facility to ensure the codes are reported at the highest specificity.
- Collaborates with coders, auditors, quality improvement teams, and other stakeholders to resolve documentation issues and improve coding accuracy.
- Stays updated on the latest developments and changes in clinical documentation standards, coding rules, and regulatory requirements.
- Assist with onboarding and training of new CDI team members.
Benefits
- annual bonus plan at a target of 5.00%
- opportunity to constantly learn
- collaborate across groups
- explore new paths for your career
- contribute, think boldly and create meaningful work that makes a difference in the communities we serve around the world
- competitive benefits package
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
Associate degree
