RN CLINICAL DOCUMENT CASE MANAGER - CDI SPECIALIST (CLINICAL DOCUMENTATION INTEGRITY)

Independence Health System • Butler Township, PA

8h • Remote

About The Position

The Clinical Documentation Case Managers are experienced nurses with clinical skills and knowledge in the application of documentation compliance necessary to support patient severity and corresponding organizational reimbursement. There is an expectation of a high level of understanding of the DRG reimbursement process and ICD-10 CM coding guidelines. The position is responsible for the improvement in overall quality, accuracy and completeness of clinical documentation, and assures all documentation describes each patient’s clinical condition as accurately as possible and supports the level of service provided. The incumbent assists to facilitate the required level of detail in clinical documentation by educating and communicating extensively with the Medical Staff, other members of the health care team and Medical Records coding staff and demonstrates improvement in metrics such as CMI, Core Measure compliance, volume of Medical Record coding queries, etc.

Requirements

• Graduate of a Registered Nurse Program
• Current PA RN license
• Three years of current medical/surgical/acute care nursing experience or two years of inpatient coding experience.

Nice To Haves

• Bachelor Degree in Nursing
• ACDIS credentialed, Certified Coding Specialist, RHIT, or RHIA
• Documentation Compliance/Coding/DRG experience.

Responsibilities

• Improve overall quality, accuracy, and completeness of clinical documentation.
• Ensure documentation accurately describes each patient’s clinical condition and supports the level of service provided.
• Facilitate the required level of detail in clinical documentation by educating and communicating extensively with the Medical Staff, other members of the health care team, and Medical Records coding staff.
• Demonstrate improvement in metrics such as CMI, Core Measure compliance, and volume of Medical Record coding queries.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: High school or GED