Clinical Documentation Integrity Registered Nurse (Sepsis Coordinator) - Full Time

IRMC Career • Indiana, PA

1d

About The Position

In this role you will: Conducts concurrent and retrospective reviews of inpatient and observation records to ensure documentation accurately reflects the patient’s clinical condition, acuity, and medical necessity. Identifies documentation improvement opportunities related to: Principal and secondary diagnoses Present on Admission (POA) indicators Severity of Illness (SOI) and Risk of Mortality (ROM) Clinical validity and CMS/payer expectations Initiates compliant physician queries following AHIMA and ACDIS standards. Collaborates with Coding, HIM, Case Management, and medical staff to support complete, accurate, and consistent documentation. Provides targeted provider education on documentation requirements, clinical indicators, and specialty‑specific best practices. Assists with denial prevention and insurance audit response through documentation clarification and clinical validation support. Monitors CDI metrics (e.g., query rate, response rate, impact, agreement rate) and contributes to CDI program reporting. Sepsis Coordinator Responsibilities Serves as the organization’s clinical subject matter expert for sepsis, severe sepsis, and septic shock. Leads compliance and ongoing performance improvement for CMS SEP‑1 and internal sepsis standards. Performs real‑time surveillance and retrospective review of suspected or confirmed sepsis cases. Tracks, analyzes, and trends core sepsis metrics including: Time to sepsis recognition Lactate and repeat lactate completion Timeliness of blood cultures Time to first antibiotic administration Fluid resuscitation compliance Vasopressor initiation, when indicated SEP‑1 exclusions, bundle failures, and case‑specific variances Identifies performance gaps and leads interdisciplinary efforts to improve bundle compliance and patient outcomes. Facilitates sepsis case reviews, root cause analyses, sepsis committee meetings, and clinical feedback loops. Assists with the development, review, and maintenance of sepsis‑related policies, procedures, pathways, order sets, and clinical workflows. Provides education to physicians, advanced practice providers, nursing staff, ED staff, and ancillary departments on sepsis recognition, treatment, and documentation expectations. Quality, Regulatory, and Performance Improvement Ensures adherence to CMS Conditions of Participation (CoPs), CMS SEP‑1 specifications, and applicable state regulatory standards. Partners with Quality to develop dashboards, quality reports, and presentations for applicable committees and workgroups as specified. Supports initiatives related to mortality reduction, patient safety, documentation accuracy, and denial mitigation. Participates in external regulatory surveys, internal readiness assessments, and mock audits related to documentation integrity and sepsis care. OTHER DUTIES Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties, or responsibilities that are required of the employee for this job. Duties, responsibilities, and activities may change at any time with or without notice.

Requirements

• Graduate of an accredited School of Nursing (ADN or BSN)
• Current Registered Nurse (RN) license in good standing
• Completion of hospital-required clinical competencies and continuing education
• Minimum 3 years of acute care clinical experience (ICU, ED, or medical‑surgical strongly preferred)
• Strong understanding of clinical documentation standards, coding principles, and evidence‑based sepsis care

Nice To Haves

• Bachelor of Science in Nursing (BSN) strongly
• Master’s degree in Nursing, Healthcare Administration, Quality, or related field ( preferred but not required)
• Formal training or coursework in: Clinical Documentation Integrity; Sepsis management / sepsis bundle compliance; Quality improvement / performance improvement; High Reliability Organization (HRO) principles desirable
• Prior CDI experience preferred
• Experience with SEP‑1 abstraction, sepsis program coordination, or quality improvement
• Background in clinical validation, coding collaboration, or payer audit support preferred
• Highly desirable: CCDS – Certified Clinical Documentation Specialist (ACDIS) CDIP – Clinical Documentation Improvement Practitioner (AHIMA) CPHQ – Certified Professional in Healthcare Quality CCRN, CEN, or other critical care/emergency specialty certifications SEP‑1 abstractor or sepsis program training/credentialing Lean Six Sigma Yellow or Green Belt

Responsibilities

• Conducts concurrent and retrospective reviews of inpatient and observation records
• Identifies documentation improvement opportunities
• Initiates compliant physician queries following AHIMA and ACDIS standards
• Collaborates with Coding, HIM, Case Management, and medical staff
• Provides targeted provider education on documentation requirements
• Assists with denial prevention and insurance audit response
• Monitors CDI metrics and contributes to CDI program reporting
• Serves as the organization’s clinical subject matter expert for sepsis, severe sepsis, and septic shock
• Leads compliance and ongoing performance improvement for CMS SEP‑1 and internal sepsis standards
• Performs real‑time surveillance and retrospective review of suspected or confirmed sepsis cases
• Tracks, analyzes, and trends core sepsis metrics
• Identifies performance gaps and leads interdisciplinary efforts to improve bundle compliance and patient outcomes
• Facilitates sepsis case reviews, root cause analyses, sepsis committee meetings, and clinical feedback loops
• Assists with the development, review, and maintenance of sepsis‑related policies, procedures, pathways, order sets, and clinical workflows
• Provides education to physicians, advanced practice providers, nursing staff, ED staff, and ancillary departments on sepsis recognition, treatment, and documentation expectations
• Ensures adherence to CMS Conditions of Participation (CoPs), CMS SEP‑1 specifications, and applicable state regulatory standards
• Partners with Quality to develop dashboards, quality reports, and presentations for applicable committees and workgroups as specified
• Supports initiatives related to mortality reduction, patient safety, documentation accuracy, and denial mitigation
• Participates in external regulatory surveys, internal readiness assessments, and mock audits related to documentation integrity and sepsis care

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree
• Number of Employees: 251-500 employees