RN2, CDI (Clinical Documentation)
About The Position
Harborview Medical Center – Clinical Documentation has an outstanding opportunity for Registered Nurse, CDI . WORK SCHEDULE 100% FTE (40 hours per week), Day Shift. The CDI RN2 is responsible for improving the overall quality and completeness of clinical documentation. Facilitates modifications to clinical documentation through extensive interaction with physicians, nursing staff, other patient caregivers, and medical records coding staff. Ensures that appropriate reimbursement is received for the level of service rendered to all patients with a MS-DRG or AP-DRG based payer. Ensures the accuracy and completeness of clinical information used for measuring and reporting physician and medical center outcomes. Educates all members of the patient care team on an ongoing basis. Facilitates modifications to clinical documentation to ensure that appropriate reimbursement is received for the level of service rendered to all patients with a DRG or APDRG based payer. Demonstrates knowledge of MS-DRG or APR-DRG payer issues, documentation opportunities, clinical documentation requirements, and referral policies and procedures. Ensures the accuracy and completeness of clinical information used for measuring and reporting physician and medical center outcomes. May educate internal customers (physicians, nurses, etc.) on compliant documentation opportunities, adding to the accuracy and specificity of the medical record. Conducts follow-up reviews of clinical documentation to ensure points of clarification have been recorded in the patient’s chart. May participate in QA studies as assigned for Quality Core Measures, Patient Safety and Hospital Acquired Conditions, referring quality issues to appropriate resources.
Requirements
- Must live in Washington State (or be willing to re-locate here upon hire)
- Current license to practice as a Registered Nurse in the State of Washington
- Minimum of 2 years in a clinical documentation improvement position
- Minimum of 6 years of recent acute inpatient hospital nursing experience with in-depth knowledge of medical and surgical care of patients
- Familiarity with Solventum 3M360 CDI tracking software and EPIC software
- Excellent observation skills, analytical thinking, problem solving, written and verbal communication skills
- Excellent interpersonal skills, professional, team player
Responsibilities
- Improving the overall quality and completeness of clinical documentation
- Facilitating modifications to clinical documentation through interaction with physicians, nursing staff, other patient caregivers, and medical records coding staff
- Ensuring appropriate reimbursement for the level of service rendered to patients with a MS-DRG or AP-DRG based payer
- Ensuring the accuracy and completeness of clinical information used for measuring and reporting physician and medical center outcomes
- Educating all members of the patient care team on an ongoing basis
- Demonstrating knowledge of MS-DRG or APR-DRG payer issues, documentation opportunities, clinical documentation requirements, and referral policies and procedures
- Educating internal customers (physicians, nurses, etc.) on compliant documentation opportunities
- Conducting follow-up reviews of clinical documentation
- Participating in QA studies as assigned for Quality Core Measures, Patient Safety and Hospital Acquired Conditions
Benefits
- For information about benefits for this position, visit https://www.washington.edu/jobs/benefits-for-uw-staff/
- $1/hour BSN premium
- $1.25/hour nursing certification premium
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
No Education Listed
Number of Employees
11-50 employees
