RN Clinical Documentation Integrity Spec, CDI & ICU exp wanted

Erlanger Health System • Chattanooga, TN

4h

About The Position

This licensed professional nurse (RN) works with the Medical Staff to offer documentation education to ensure an accurate and complete medical record with documentation that allows for codeable diagnosis and/or procedures. He/she works within the scope of the HIM Department to provide documentation that best represents the patient's clinical findings and treatment plan. This professional is also responsible for data quality review on specified records, resolution of DRG/APG/ASC coding changes with third party payers and provides structured education programs. The candidate must be able to follow standard practices in
coding/reimbursement and to optimize payment for all financial schemes. He/she must demonstrate exceptional judgment and organizational ability and possess excellent communication skills, both written and oral.

Department Position Summary:
Responsible for communication with the medical staff to improve the quality and clarity of documentation of patients condition in the medical record. Reduces physician's workload through assistance with regulatory guides through clinical review. Supports documentation of clinically supported procedures.

When documentation is incomplete, vague, or ambiguous, it is the responsibility of the CDI nurse to utilize the appropriate physician clarification process to obtain additional information that provides a codeable diagnosis, procedure. Reviews inpatient medical records to assign and sequence all appropriate diagnosis and procedures codes utilizing encoder software and proficiently translating diagnostic statements, physician orders, and other pertinent documentation. Reviews Medicare Severity Diagnosis Related Groups (MSDRGs) and All Patient Refined Diagnosis Related Groups (APRDRGs) on inpatient cases. Reviews appropriate CDI work lanes daily to address coding edits and needed corrections and follows procedure as needed to resolve these cases. Reviews accounts and performs needed correction for internal audits.

This position may be assigned 2nd level review cases based on defined department processes. The CDI nurse will review these cases and follow department process for communication on missed findings.

The employee must be detail oriented and able to assimilate large quantities of data, analyze the data and provide organized reports on the data. The employee must be able to demonstrate knowledge of problem identification and resolution. The individual must demonstrate the ability and desire to learn intense optimization techniques. The employee must be able to research data gathered and organize the data into a comprehensive educational presentation. The individual must have the professional demeanor needed to present education programs to various audience types. The individual must demonstrate flexibility in the scope and type of work assigned.

The employee in this position must display the ability to be self-motivated, able to evaluate the scope of each day's work and display time management skills to accomplish the work evaluated. The employee must keep her/his licensure current by participating in continuing education.

Requirements

• Registered Nurse in the state of TN
• Strong clinical background (minimum of five years bed side nursing)
• Computer literate with experience in Microsoft Office and/or Excel
• Current license to practice nursing in the State of Tennessee
• Tennessee licensure or multistate licensure from a compact state must be obtained within three months of hire for non-Tennessee residents
• Exceptional judgment and organizational ability
• Excellent communication skills, both written and oral
• Detail oriented
• Able to assimilate large quantities of data, analyze the data and provide organized reports on the data
• Demonstrate knowledge of problem identification and resolution
• Demonstrate the ability and desire to learn intense optimization techniques
• Able to research data gathered and organize the data into a comprehensive educational presentation
• Professional demeanor needed to present education programs to various audience types
• Demonstrate flexibility in the scope and type of work assigned
• Ability to be self-motivated
• Able to evaluate the scope of each day's work and display time management skills to accomplish the work evaluated
• Keep her/his licensure current by participating in continuing education

Nice To Haves

• BSN
• MSN
• Understanding of reimbursement principles and/or coding concepts
• Experience with 3M 360
• CCDS or CDIP

Responsibilities

• Offer documentation education to ensure an accurate and complete medical record
• Provide documentation that best represents the patient's clinical findings and treatment plan
• Responsible for data quality review on specified records
• Resolution of DRG/APG/ASC coding changes with third party payers
• Provide structured education programs
• Follow standard practices in coding/reimbursement
• Optimize payment for all financial schemes
• Communicate with the medical staff to improve the quality and clarity of documentation of patients condition in the medical record
• Reduce physician's workload through assistance with regulatory guides through clinical review
• Support documentation of clinically supported procedures
• Utilize the appropriate physician clarification process to obtain additional information that provides a codeable diagnosis, procedure
• Review inpatient medical records to assign and sequence all appropriate diagnosis and procedures codes utilizing encoder software and proficiently translating diagnostic statements, physician orders, and other pertinent documentation
• Review Medicare Severity Diagnosis Related Groups (MSDRGs) and All Patient Refined Diagnosis Related Groups (APRDRGs) on inpatient cases
• Review appropriate CDI work lanes daily to address coding edits and needed corrections and follows procedure as needed to resolve these cases
• Review accounts and performs needed correction for internal audits
• Review 2nd level review cases and follow department process for communication on missed findings
• Adherence to Health Information Management (HIM) Coding and CDI policies
• Interpret and apply American Hospital Association (AHA) Official Coding Guidelines to articulate and support appropriate principal, secondary diagnoses and procedures
• Adherence to Det Norske Veritas (DNV) and other third-party documentation guidelines in an effort to continually improve coding quality and accuracy
• Responsibility for maintaining knowledge referencing current diagnosis and procedural coding, coding guidelines and regulatory changes
• Contact the appropriate department or physician for assistance in obtaining physician clarification of diagnoses
• Participate in performance improvement initiatives as assigned
• Consistently meet or exceed productivity and quality standards as defined by department Leadership

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree