RN Nurse, Clinical Documentation Improvement Specialist

This is a fully remote position, open to applicants in Alabama, +5 more states.

📋 Description

• Perform both concurrent and retrospective clinical reviews of inpatient medical records.

• Assess clinical service documentation to pinpoint areas for enhancement in medical record documentation.

• Carry out mortality reviews, PSI reviews, and other specialized reviews as directed by CDI leadership.

• Facilitate and secure appropriate physician documentation that supports severity of illness, anticipated risk of mortality, and care complexity.

• Initiate physician engagement through the physician query process and/or involvement in physician rounding.

• Provide education to physicians and other staff regarding documentation requirements, coding guidelines, and reimbursement policies.

• Assign working DRGs and review patient records during hospitalization to ensure that codes are reported with maximum specificity.

• Collaborate with coders, auditors, quality improvement teams, and other stakeholders to address documentation issues and enhance coding accuracy.

• Engage in documentation improvement initiatives and both formal and informal educational programs for providers and the CDI team.

• Remain informed about clinical documentation standards, coding regulations, and compliance requirements.

⛳️ Requirements

• Associate’s Degree in Nursing is required.

• Bachelor’s Degree in Nursing is preferred.

• An active US RN license is mandatory.

• Experience in front line CDI within an acute care hospital.

• Three to five years of recent clinical experience in medical-surgical, ICU, telemetry, and/or emergency department settings.

• Familiarity with electronic medical records (EMR) platforms and CDI systems.

• Proficient in CDI practices, coding, and documentation standards related to quality outcomes, medical record data accuracy, and reimbursement.

• Ability to stay current with CMS rules and regulations.

• Clinical experience in ICU, medical-surgical, telemetry, or emergency department.

• Understanding of hospital coding code sets, policies and procedures, as well as federal and state coding reimbursement guidelines and Coding Clinic Guidelines.

🏝️ Benefits

• Annual bonus plan with a target of 5.00%.

• Competitive benefits package.

• Opportunities for learning, collaboration across groups, and exploring new career paths.

• Chance to contribute, think innovatively, and engage in meaningful work.

• Support for reasonable accommodations during the application process.