Clinical Documentation Improvement Specialist

Emory HealthcareAtlanta, GA
$45 - $52Onsite

About The Position

Provides clinically based concurrent and retrospective review of inpatient medical records to evaluate the documentation of patient acuity and to support acute care services that were delivered. The goal of concurrent review includes facilitation of appropriate physician documentation of care delivery to accurately reflect patient severity of illness and risk of mortality. Specific reviews are both determined internally and by requirements/requests of external payers or regulatory agencies and play a significant role in reporting quality of care outcomes and in obtaining accurate and compliant documentation for billing of services rendered.

Requirements

  • Graduate of an accredited school of Nursing, or United States or International School of Medicine Education.
  • For RNs, candidates must have an active license. All nurses employed in roles requiring an unencucumbered nursing license must have a valid, active license or temporary permit approved by the Georgia Licensing Board.
  • Three years' experience in healthcare related field with strong clinical expertise and acumen.
  • Recent clinical experience in an acute care setting (Critical Care, Medical/Surgical or Emergency department nursing preferred; or 2 years' experience in a specialty area).
  • Light physical requirements: 0-33% of the work day (occasionally), negligible 34-66% of the workday (frequently), negligible 67-100% of the workday (constantly).
  • Lifting 10 lbs max, carrying of small articles such as dockets, ledgers, files, small tools.
  • Occasional standing & walking.
  • Frequent sitting.
  • Close eye work (computers, typing, reading, writing).
  • Awareness of potential environmental exposures including blood-borne pathogens, bio-hazardous waste, chemicals/gases/fumes/vapors, communicable diseases, electrical shock, floor surfaces, hot/cold temperatures, indoor/outdoor conditions, latex, lighting, patient care/handling injuries, radiation, shift work, use of personal protective equipment, including respirators.

Nice To Haves

  • Education and experience may be considered in lieu of a RN license for highly qualified candidates (physician).

Responsibilities

  • Provides clinically based concurrent and retrospective review of inpatient medical records to evaluate the documentation of patient acuity and to support acute care services that were delivered.
  • Facilitates appropriate physician documentation of care delivery to accurately reflect patient severity of illness and risk of mortality.
  • Conducts specific reviews determined internally and by requirements/requests of external payers or regulatory agencies.
  • Plays a significant role in reporting quality of care outcomes.
  • Ensures accurate and compliant documentation for billing of services rendered.

Benefits

  • Comprehensive health benefits that start day 1
  • Student Loan Repayment Assistance & Reimbursement Programs
  • Family-focused benefits
  • Wellness incentives
  • Ongoing mentorship, development, and leadership programs
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