[Hiring] Clinical Documentation Improvement Specialist @R1 RCM

Role Description

As our Clinical Documentation Improvement (CDI) Specialist, you will use clinical and coding knowledge for conducting clinically based concurrent and retrospective reviews of inpatient medical records. Every day, you will:

• Evaluate the documentation of clinical services by identifying opportunities for improving the quality of medical record documentation.
• Conduct focused reviews in areas identified by CDI leadership: Mortality reviews, PSI reviews, and other identified projects.
• Facilitate and obtain 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.
• Participate in ongoing documentation improvement initiatives, including formal and informal education plans related to clinical documentation improvement to providers and the CDI team.

Qualifications

• Highly skilled in CDI practices, coding, and documentation requirements related to quality outcomes.
• 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.
• Active RN license with experience in ICU, Med surge, telemetry, or ED.

Requirements

• Associate’s Degree in Nursing (Bachelor’s Degree in Nursing is preferred).
• An active US RN license is required.
• 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.

Benefits

• Competitive benefits package.
• Opportunity to constantly learn and collaborate across groups.
• Chance to contribute, think boldly, and create meaningful work that makes a difference in the communities served.