Registered Nurse (RN) | Clinical Documentation Specialist

Avera•Sioux Falls, SD

1d•Onsite

About The Position

The RN-Clinical Documentation Specialist (CDI) reviews medical records to ensure accuracy and completeness of the medical records to ensure accurate coding of the record. The CDI role is complex and requires expert knowledge of clinical care and applicable coding guidelines, as well as an ability to communicate effectively with the clinical team. This role collaborates with clinicians, physicians, and HIM coding staff to ensure timely and accurate documentation and provides training and education as needed. Demonstrates a willingness to maintain awareness of the business of medicine and transitional healthcare changes including but not limited to value-based purchasing, accountable care organizations and the readmission reduction program.

Requirements

Must be able to work the hours specified.
Must be able to perform each essential job function satisfactorily including having visual acuity adequate to perform position duties and the ability to communicate effectively with others, hear, understand and distinguish speech and other sounds.
Certified Clinical Documentation Specialist (CCDS) - Association of Clinical Documentation Integrity Specialists (ACDIS) within 3 Years
Registered Nurse (RN) - Board of Nursing
An active license in the state of practice Upon Hire

Nice To Haves

4-6 years Related inpatient clinical experience
Knowledge of hospital revenue cycle and the electronic health record.

Responsibilities

Accurately reviews the entire inpatient medical record (dictation, templates, lab, orders, and nursing notes) to determine appropriate coding utilizing: ICD-9-CM, ICD-10 (CM and PCS), DRG Grouper and APR-DRG Grouper for strategizing SOI, ROM and DRG assignment.
Utilizing advanced experience and in-depth knowledge, accurately determines the appropriate sequence of principle diagnosis code, procedure codes, MS-DRG/APR- DRG, SOI, ROM and POA reporting on Inpatient Coding Product Lines.
Concurrent coding may be required on all product lines.
Familiarity with Inpatient Prospective Payment System (IPPS), including new CMS guidelines related to clinical documentation, coding and reimbursement.
Serves as a resource and provides subject matter expertise to Providers, HIM and/or coders, and other clinical entities as needed.
Prompts providers/physicians/residents regarding missing, unclear, or conflicting medical record documentation and obtains additional documentation with the medical record when needed.
Devoted to ongoing, continuous learning and provides relevant updates and happenings in the business of medicine directly impacting physicians such as documentation, CDI guidelines, coding guidelines, and CDI and coding policies.
Maintains personal quality and production statistics in accordance to CDI standards.
Ability and willingness to seek out changes in healthcare reform and coding regulations then incorporate those changes into chart review and educational responsibilities.
Ability to conduct independent research to promote knowledge of clinical topics, coding guidelines, regulatory policies and trends, and healthcare economics.
Performs and participates in performance improvement activities, such as identifying documentation requirements for the legal record.