CDI Clinical Documentation Integrity Registered Nurse RN- Hybrid

Tenet Healthcare Corporation • Anniston, AL

1d • Hybrid

About The Position

This is a hybrid role for a Clinical Documentation Integrity Registered Nurse (RN) who must live within 1 hour of Anniston, AL. The primary responsibility is to review medical records to ensure appropriate physician documentation for clinical conditions and procedures. This role aims to support accurate severity of illness, expected risk of mortality, and complexity of care by enhancing the quality of physicians' clinical documentation. The position requires a strong understanding of clinical documentation requirements, MS-DRG assignment, and clinical conditions/procedures. The RN will also educate patient care team members, including physicians, allied health practitioners, nursing staff, and case managers, on documentation guidelines.

Requirements

• Proficient knowledge of disease pathophysiology and drug utilization
• Intermediate knowledge of MS-DRG classification and reimbursement structures
• Critical thinking, problem solving and deductive reasoning skills
• Effective written and verbal communication skills
• Excellent computer skills including MS Word/Excel
• Knowledge of coding compliance and regulatory standards
• Excellent organizational skills for initiation and maintenance of efficient workflow
• Regular and reliable attendance
• Capacity to work independently in facility on-site setting
• Capacity to work independently in a virtual office setting if required for specific assignment
• Exhibit flexibility as needed to meet program needs
• Understand and communicate documentation strategies
• Recognize opportunities for documentation improvement
• Formulate clinically, compliant credible queries
• Ability to successfully comply to robust auditing and CDI program monitoring
• Ability to apply coding conventions, official guidelines, and Coding Clinic advice to health record documentation
• Active state Registered Nurse license; OR Graduate MD and/or FMD license

Nice To Haves

• Acute Care nursing and/or Provider relevant experience
• CDIP or CCDS certification
• Travel may be required to meet the needs of the facilities.

Responsibilities

• Completes initial medical records reviews of patient records within 24-48 hours of admission to evaluate documentation for accurate MS-DRG assignment, risk of mortality, and severity of illness, and records findings in the designated CDI tool and/or medical record system.
• Conducts follow-up reviews of patients every 24-48 hours or as needed up through discharge to support assigned working MS-DRG assignment.
• Formulates physician queries regarding missing, unclear, or conflicting health record documentation.
• Collaborates with providers, case managers, nursing staff, and other ancillary staff regarding documentation and to resolve physician queries prior to discharge.
• Communicates and completes Clinical Documentation Integrity (CDI) activities and coding issues for appropriate follow-up, provider education, and DRG Miss-Match reconciliation.
• Assists with Provider education, rounding, and communication regarding open queries for resolution.
• Stays current with AHA Official Coding and Reporting Guidelines, CMS, and other agency directives for ICD10-CM and PCS coding.
• Attends CDI Boot camp, CDI/coding trainings annually and quarterly for inpatient coding.
• Attends monthly education lecture series (MELS) and all CDI/coding assigned learn share modules, as well as any additional required CDI education.
• Assists in training department staff new to CDI.
• Performs other duties as assigned.

Benefits

• Conifer requires its candidates, as applicable and as permitted by law, to obtain and provide confirmation of all required vaccinations and screenings prior to the start of employment. This may include, but is not limited to, the COVID-19 vaccination, influenza vaccination, and/or any future required vaccines and screenings.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree