Registered Nurse (RN) - CDI (Hybrid)

Conifer Health Solutions•Birmingham, AL

3d•Hybrid

About The Position

This role is responsible for reviewing medical records to facilitate and obtain appropriate physician documentation for clinical conditions or procedures. The goal is to support the appropriate severity of illness, expected risk of mortality, and complexity of care of the patient by improving the quality of physicians’ clinical documentation. The position requires a strong understanding of clinical documentation requirements, MS-DRG Assignment, and clinical conditions/procedures. The Registered Nurse will also educate members of the patient care team, including attending physicians, allied health practitioners, nursing, and case management, on documentation guidelines.

Requirements

Must live within 1 hour of Birmingham, AL
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
Graduate MD and/or FMD license

Nice To Haves

Acute Care nursing and/or Provider relevant experience
Zero (0) to two (2) years CDI experience
Two (2) plus years’ nursing experience – Medical/Surgical/Intensive Care and/or Case/Utilization Review
Two (2) plus years’ Provider experience – Medical/Surgical/Intensive Care and/or Case/Utilization Review
Graduate from a Nursing program, BSN, or graduate program; OR Graduate from Medical Doctor and/or Foreign Medical Doctor Program
CDIP or CCDS

Responsibilities

Completes initial medical records reviews of patient records within 24-48 hours of admission for a specified patient population to evaluate documentation for accurate MS-DRG assignment, risk of mortality, and severity of illness.
Records review findings in the designated CDI tool and/or host 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 and obtains additional 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.