RN CDI Specialist

2 weeks ago

Washington, Washington, D.C., United States Children's National Full time

RN Clinical Documentation Integrity Specialist

Description: The CDI RN Specialist's main role is to ensure the quality and completeness of clinical documentation for specific patient populations. This involves working closely with physicians and other healthcare team members to ensure accurate recording of the severity of illness, risk of mortality, and complexity of care provided to inpatients.

About the Company: Children's National is dedicated to providing high-quality healthcare services for children.

Qualifications

  • Minimum Education: BSN (Required)
  • Minimum Work Experience: 5 years of experience, with at least 3 years in clinical nursing (Required)

Responsibilities

Professional Practice/Research

  • Participate in Shared Leadership
  • Contribute to the MAGNET Journey of Children's National
  • Ensure nursing practice is based on evidence of best practices
  • Participate in the Nursing Division's Performance Improvement process
  • Engage in community activities

Clinical Documentation

  • Conduct daily clinical evaluation of medical records, including physician and clinical documentation, lab results, diagnostic information, and treatment plans
  • Collaborate with Coder CDI Specialist on physician documentation
  • Communicate with physicians regarding missing or unclear medical record documentation
  • Apply recognized criteria to support physician queries
  • Coordinate documentation evaluation by the medical staff

Program Activities

  • Target activities to specific payers, DRGs, and teams based on data analysis
  • Collect and analyze data on program outcomes
  • Assist in reporting performance measures to the medical staff
  • Facilitate change process to capture necessary documentation
  • Develop education strategies for physicians/providers

Communication

  • Communicate verbally and via email with physicians and healthcare team members

Performance Improvement

  • Ensure compliance with federal regulations
  • Identify opportunities for documentation improvement
  • Promote accurate clinical documentation
  • Educate team members on documentation needs
  • Participate in departmental and hospital committees

Organizational Accountabilities

  • Anticipate and respond to customer needs
  • Demonstrate teamwork and effective communication
  • Contribute to a positive work environment
  • Identify ways to improve processes
  • Use resources efficiently
  • Promote safety for all

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