Clinical Documentation Integrity Nurse-Desert
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About The Position
The Clinical Documentation Integrity Nurse (CDI RN) utilizes clinical expertise, expert coding knowledge, and critical thinking skills to work collaboratively with Medical Directors. This position provides high-level expertise in the areas of coding and contracting, insurance regulations, and risk adjustment capitated revenue. Nurses review complex clinical provider notes and communicate with providers to meticulously identify ambiguous documentation or discrepancies between documentation and the patient's clinical presentation. This position also provides education and training to customers (physicians, mid-level providers, office staff) on clinical indicators and risk adjustment capitated revenue. Ensure clinical documentation is accurate, specific, complete, and compliant to reflect the severity of illness and risk of mortality of the patient. Work collaboratively with providers to identify opportunities for the accuracy and quality of chart documentation. Identify complications and co-morbid conditions, specify co-existing and causal conditions, and follow up with providers responsible for the care of the patient for appropriate documentation. Identify the need to clarify documentation in the medical record by communicating with providers face-to-face or in written communication. Stay abreast of coding guidelines, risk adjustment payment methodologies, regulatory compliance, and quality-based programs. Maintain thorough and current knowledge of clinical care and treatment options to critically assess the accuracy and appropriateness of documentation. Maintain thorough clinical knowledge of disease processes, pathophysiology, and pharmacology. Demonstrate excellent communication and interaction skills to diplomatically handle difficult, complex, and/or potentially political situations with physicians, office staff during clinic in-person on-site work, and other external and internal customers and departments. Serve as a resource for providers to educate on linking coding guidelines and medical terminology to capture opportunities. Perform other duties as assigned, including but not limited to the orientation of caregivers.
