RN, Clinical Documentation Specialist (CDI)
About The Position
The RN, Clinical Documentation Specialist (CDI) role involves extensive record review and interaction with physicians, HIM professionals, and nursing staff. A key part of this role is active participation in team meetings and educating staff on the CDI process. The specialist must be able to learn and develop the necessary skills to perform CDI duties, conduct accurate and timely record reviews, and recognize opportunities for documentation improvement. This includes formulating clinically credible queries, communicating effectively and appropriately with physicians, and timely follow-up on all cases, especially those with queries. The role also requires participation in Task Force meetings, managing multiple priorities, and communicating with HIM staff to resolve discrepancies. Accurate data input into the electronic medical record and supporting clinical documentation strategies are essential. The position demands consistent service excellence to all patients, family members, visitors, volunteers, and co-workers. A thorough understanding of the differences between Medicare Part A and Part B guidelines and their impact on DRG assignments is also required.
Requirements
- Graduate of a School of Nursing (RN)
- Currently licensed as a Registered Nurse in the Commonwealth of Massachusetts
- Bachelor of Science in Nursing (BSN) – (external applicants only)
- Minimum of 3 years of current RN, CDI Practice experience
- Must meet at least one of the following qualifications: Certified Clinical Documentation Specialist (CDIS) or CCHC Clinical Documentation Specialist Exam
- Knowledge of Medicare Part A and Part B
- Knowledge of regulatory environment
- Organizational, analytical, writing and interpersonal skills
- Dependable and self-directed
- Critical thinking, problem solving and deductive reasoning skills
- Knowledge of pathophysiology and disease process
- Basic computer skills – familiarity with Windows based software programs
- Strong interpersonal and negotiation skills demonstrated by a positive attitude, pleasant, professional and cooperative demeanor with physicians, fellow employees & all customers
Responsibilities
- Extensive record review
- Interaction with physicians, HIM professionals, and nursing staff
- Active participation in team meetings
- Education of staff in the CDI process
- Accurate and timely record review
- Recognize opportunities for documentation improvement
- Formulate clinically credible queries
- Effective and appropriate communication with physicians
- Timely follow up on all cases especially those with queries
- Participate in Task Force meetings
- Manage multiple priorities
- Communicates with HIM staff and resolves discrepancies
- Accurate input of data into the electronic medical record
- Understand and support clinical documentation strategies
- Consistently provides service excellence to all patients, family members, visitors, volunteers and co-workers
- Understand and communicate differences between Medicare Part A and Part B guidelines and how they impact DRG assignments
Stand Out From the Crowd
Upload your resume and get instant feedback on how well it matches this job.
What This Job Offers
Job Type
Full-time
Career Level
Mid Level
