RN Nurse Clinical Documentation Improvement Specialist

R1 RCM • Remote, FL, IN

4d

About The Position

R1 is a leading provider of technology-driven solutions that transform the patient experience and financial performance of hospitals, health systems, and medical groups. This role utilizes clinical and coding knowledge for conducting clinically based concurrent and retrospective reviews of inpatient medical records. The specialist will evaluate the documentation of clinical services, identifying opportunities for improving the quality of medical record documentation, including focused reviews in areas identified by CDI leadership: Mortality reviews, PSI reviews, and other identified projects. The role facilitates and obtains appropriate physician documentation for any clinical conditions or procedures to support the appropriate severity of illness, expected risk of mortality, and complexity of care of the patient. It also participates in ongoing documentation improvement initiatives, including formal and informal education plans related to clinical documentation improvement to providers and the CDI team.

Requirements

• Highly skilled in CDI practices, coding, and documentation requirements related to quality outcomes, evaluation of medical record data for accuracy and reimbursement.
• Self-motivated to stay abreast of CMS rules and regulations and incorporate those changes into daily practice.
• Front Line CDI experience in an acute care hospital.
• An active US RN license is required.
• Associate’s Degree in Nursing.
• Must have front line CDI experience in an acute care hospital.
• Three to five years of recent clinical work experience in the medical-surgical area, ICU, telemetry, and or emergency department.
• Knowledge or experience in electronic medical records (EMR) platforms and CDI platforms.

Nice To Haves

• Bachelor’s Degree in Nursing is preferred.
• Experience in ICU, Med surge, telemetry, or ED.

Responsibilities

• Conducts clinically based concurrent and retrospective reviews of inpatient medical records.
• Evaluates the documentation of clinical services, identifying opportunities for improving the quality of medical record documentation.
• Conducts focused reviews in areas identified by CDI leadership: Mortality reviews, PSI reviews, and other identified projects.
• Facilitates and obtains appropriate physician documentation for any clinical conditions or procedures to support the appropriate severity of illness, expected risk of mortality, and complexity of care of the patient.
• Participates in ongoing documentation improvement initiatives, including formal and informal education plans related to clinical documentation improvement to providers and the CDI team.
• Initiates physician interaction when ambiguous, missing, or conflicting information is in the medical record, through the physician query process and/or participation in rounding with the physicians by requesting additional documentation for correct coding and compliance necessary for accurate reflection of CMI, LOS, and optimal resource utilization.
• Educates physicians and other staff on documentation requirements, coding guidelines, and reimbursement policies.
• Utilizes Hospital coding code set, policies and procedures, Federal and State coding reimbursement guidelines, and application of the Coding Clinic Guidelines to assign working DRG, reviewing patient records throughout hospitalization that have been identified as focus DRG by regulatory agencies or the facility to ensure the codes are reported at the highest specificity.
• Collaborates with coders, auditors, quality improvement teams, and other stakeholders to resolve documentation issues and improve coding accuracy.
• Stays updated on the latest developments and changes in clinical documentation standards, coding rules, and regulatory requirements.

Benefits

• Competitive benefits package

What This Job Offers

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