Clinical Specialist Jobs

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RN Clinical Documentation Specialist Senior-Full Time

Centra HealthLynchburg, VA
$37 - $53

About The Position

The Clinical Documentation Integrity Specialist II (CDI) is responsible for utilizing independent clinical judgment in facilitating the integrity, overall quality, accuracy, and completeness of provider-based clinical documentation in the medical record. This position is responsible for collaborating with healthcare providers to ensure the documentation in the medical record accurately reflects the severity of illness and risk of mortality of the patient. The CDI Specialist assesses the clinical documentation through extensive reviews of the medical record, interaction with all members of the healthcare team and the Healthcare Information Management (HIM) Coding team to ensure appropriate coding and Diagnosis Related Group (DRG) assignment for the level of services rendered to the patient and to ensure that the clinical information utilized in profiling and reporting outcomes is complete and accurate.

Requirements

  • Registered Nurse (RN) license
  • Clinical judgment
  • Knowledge of medical records
  • Collaboration skills
  • Interaction with healthcare teams
  • Understanding of coding and DRG assignment

Responsibilities

  • Utilize independent clinical judgment to facilitate the integrity, overall quality, accuracy, and completeness of provider-based clinical documentation in the medical record.
  • Collaborate with healthcare providers to ensure documentation accurately reflects patient's severity of illness and risk of mortality.
  • Assess clinical documentation through extensive reviews of the medical record.
  • Interact with all members of the healthcare team and the Healthcare Information Management (HIM) Coding team.
  • Ensure appropriate coding and Diagnosis Related Group (DRG) assignment for the level of services rendered.
  • Ensure clinical information used in profiling and reporting outcomes is complete and accurate.

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