CDI RN SPECIALIST
3 weeks ago
Responsible for reviewing medical records to 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, by improving the quality of the physicians' clinical documentation. Exhibits a sufficient knowledge of clinical documentation requirements, MS-DRG Assignment, and clinical conditions or procedures, Educates members of the patient care team regarding documentation guidelines, including attending physicians, allied health practitioners, nursing, and case management.
ESSENTIAL DUTIES AND RESPONSIBILITIES
Include the following. Others may be assigned.
* Record Review: Completes initial medical records reviews of patient records within 24-48 hours of admission for a specified patient population to: (a) evaluate documentation to assign the principal diagnosis, pertinent secondary diagnoses, and procedures for accurate MS-DRG assignment, risk of mortality and severity of illness; and (b) initiate a review worksheet.
* Conducts follow-up reviews of patients every 2-3 days to support and assign a working or final MS-DRG assignment upon patient discharge, as necessary.
* Formulate physician queries regarding missing, unclear or conflicting health record documentation by requesting and obtaining additional documentation within the health record, as necessary.
* Collaborates with case managers, nursing staff and other ancillary staff regarding interaction with physicians regarding documentation and to resolve physician queries prior to discharge.
* Assist in training department staff new to CDI
* Professional Development: Stays current with AHA Official Coding and Reporting Guidelines, CMS and other agency directives for ICD-9-CM and CPT coding. Attends mandatory coding seminars on annual basis (IPPS and OPPS, ICD-9-CM and CPT updates) for inpatient and outpatient coding. Quarterly review of AHA Coding Clinic. Attends Quarterly Coding Updates and all coding conference calls as well as any required CDI education.
* CDI: Communicates/Completes Clinical Documentation Improvement (CDI) activities and coding issues (lacking documentation, physician queries, etc.) for appropriate follow-up and resolution
* Other duties as assigned
Conifer requires its candidates, as applicable and as permitted by law, to obtain and provide confirmation of all required vaccinations and screenings prior to the start of employment. This may include, but is not limited to, the COVID-19 vaccination, influenza vaccination, and/or any future required vaccines and screenings.
KNOWLEDGE, SKILLS, ABILITIES
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
* CDI Specialist must display teamwork and commitment while performing daily duties
* Must demonstrate initiative and discipline in time management and medical record review
* Travel may be required to meet the needs of the facilities
* Advanced knowledge of Medicare Part A and familiar with Medicare Part B
* Intermediate knowledge of disease pathophysiology and drug utilization
* Intermediate knowledge of MS-DRG classification and reimbursement structures
* Critical thinking, problem solving and deductive reasoning skills
* Effective written and verbal communication skills
* Knowledge of coding compliance and regulatory standards
* Excellent organizational skills for initiation and maintenance of efficient work flow
* Regular and reliable attendance and time reporting per Conifer Telecommuting program requirements
* Capacity to work independently in a virtual office setting or at facility setting if required to travel for assignment
* Understand and communicate documentation strategies
* Recognize opportunities for documentation improvement
* Formulate clinically, compliant credible queries
* Ability to maintain an auditing and monitoring program as a means to measure query process
* Ability to apply coding conventions, official guidelines, and Coding Clinic advice to health record documentation
EDUCATION / EXPERIENCE
Include minimum education, technical training, and/or experience required to perform the job.
* Preferred: Acute Care nursing relevant experience
* Zero (0) to two (2) years experience
* Graduate from a Nursing program, BSN, or graduate
CERTIFICATES, LICENSES, REGISTRATIONS
* Active state Registered Nurse license
* Preferred: CDIP or CCDS
PHYSICAL DEMANDS
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
* Ability to sit for extended periods of time
* Must be able to efficiently use computer keyboard and mouse
* Good visual acuity
WORK ENVIRONMENT
The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
OTHER
* Must be able to travel nationally as needed, not to exceed 10%
As a part of the Tenet and Catholic Health Initiatives family, Conifer Health brings 30 years of healthcare industry expertise to clients in more than 135 local regions nationwide. We help our clients strengthen their financial and clinical performance, serve their communities and succeed at the business of healthcare. Conifer Health helps organizations transition from volume to value-based care, enhance the consumer and patient healthcare experience and improve quality, cost and access to healthcare. Are you ready to be part of our solutions? Welcome to the company that gives you the resources and incentives to redefine healthcare services, with a competitive benefits package and leadership to take your career to the next step
2403012571
-
CDI RN Specialist
9 hours ago
Bismarck, ND, United States Tenet Healthcare Corporation Full timeJOB SUMMARY Responsible for reviewing medical records to 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, by improving the quality of the physicians' clinical documentation. Exhibits a...
-
CDI RN Specialist
14 hours ago
Bismarck, ND, United States Tenet Healthcare Corporation Full timeJOB SUMMARY Responsible for reviewing medical records to 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, by improving the quality of the physicians' clinical documentation. Exhibits a...
-
CDI RN SPECIALIST
3 weeks ago
, ND, United States Tenet Healthcare Corporation Full timeJOB SUMMARYResponsible for reviewing medical records to 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, by improving the quality of the physicians' clinical documentation. Exhibits a sufficient...
-
CDI RN SPECIALIST
3 weeks ago
Washington, DC 20319, USA, United States Children's National Medical Center Full timeThe CDI RN Specialist will ensure overall quality and completeness of clinical documentation for specified populations. Will facilitate modifications to clinical documentation through concurrent interaction with physicians and other members of the healthcare team to support (1) the appropriate severity of illness, (2) expected risk of mortality, and (3)...
-
CLINICAL DOCUMENTATION IMPROVEMENT
6 days ago
Brooklyn, NY 11210, USA, United States SUNY Downstate Medical Center Full timeThe Department of Health Information Management at SUNY Downstate Health Sciences University is seeking a full-time TH Utilization Review and Quality Assurance Senior Coordinator / Clinical Documentation Improvement (CDI) Specialist. Reporting to the Clinical, Specialist, Improvement, Improvement, Leadership, Medical, Healthcare, Education
-
CDI RN SPECIALIST
4 days ago
Roseburg, OR 97470, USA, United States Tenet Healthcare Corporation Full timeJOB SUMMARYResponsible for reviewing medical records to 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, by improving the quality of the physicians' clinical documentation. Exhibits a sufficient...
-
CDI SPECIALIST III REGISTERED NURSE
3 weeks ago
Orlando, FL 32801, USA, United States Orlando Health Full timePosition SummaryProvides concurrent review of the clinical documentation in the medical record; review the medical record with a clinical lens to identify any missing or understated diagnoses or procedures.QualificationsEducation/TrainingGraduate from an approved school of nursing.Licensure/CertificationMaintains current State of Florida RN license or valid...
-
CDI RN SPECIALIST
3 weeks ago
Lufkin, TX 75902, USA, United States Tenet Healthcare Corporation Full timeJOB SUMMARYResponsible for reviewing medical records to 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, by improving the quality of the physicians' clinical documentation. Exhibits a sufficient...
-
CDI RN SPECIALIST
4 weeks ago
Omaha, NE 68102, USA, United States Tenet Healthcare Corporation Full timeJOB SUMMARYResponsible for reviewing medical records to 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, by improving the quality of the physicians' clinical documentation. Exhibits a sufficient...
-
REGISTERED NURSE
3 weeks ago
Syracuse, NY 13201, USA, United States Crouse Hospital Full timeThe Clinical Documentation Improvement Specialists (CDIS) report to the Director of Health Information Management.# The CDS is responsible for reviewing medical records to facilitate the accurate representation of severity of illness.# This involves extensive record review, interaction with physicians, HIM professionals and nursing staff.# Active...
-
CDI RN SPECIALIST
2 days ago
Council Bluffs, IA 51501, USA, United States Tenet Healthcare Corporation Full timeJOB SUMMARYResponsible for reviewing medical records to 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, by improving the quality of the physicians' clinical documentation. Exhibits a sufficient...
-
CDI RN
1 week ago
Spring, TX 77380, USA, United States Tenet Healthcare Corporation Full timeJOB SUMMARYResponsible for reviewing medical records to 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, by improving the quality of the physicians' clinical documentation. Exhibits a sufficient...
-
CLINICAL DOCUMENT IMPROVEMENT SPECIALIST
2 weeks ago
Philadelphia, PA 19107, USA, United States Temple University Health System Full timeServes as the primary resource to the treatment team on all aspects of medical record documentation required to support the accurate classification of patient's severity of illness/medical complexity. Possess extensive knowledge of both clinical medicine and disease management, as well as the internal and external patient classification systems that measure...
-
CARDIAC DEVICE NURSE SPECIALIST
1 week ago
Bismarck, ND 58502, USA, United States Common Spirit Full timeOverviewSince 1885, CHI St. Alexius Health has been dedicated to leading health care in this region by enriching the lives of patients through the highest quality of care. We seek to continue our tradition of success and innovation with individuals dedicated to delivering the highest level of expertise and quality. Together we can continue to grow and...
-
El Centro, CA 92244, USA, United States El Centro Regional Medical Center Full timePOSITION SUMMARY:The Clinical Documentation Improvement Specialist (CDIS) performs concurrent and retrospective reviews of medical records for opportunities to improve physician documentation. The CDIS position collaborates extensively with physicians to ensure documentation accurately, ethically, and compliantly reflects, captures, and reports patient...
-
PRN REGISTERED NURSE, RN
4 days ago
Shirley Center, MA 01464, USA, United States CDI Health Full timeWhy Join CharDonnay Dialysis?We are a family owned and operated company founded over 25 years ago by a Dialysis RN who believes that everyone is entitled to excellent medical treatment provided by talented clinicians.Whats In It For You?Our company offers competitive compensation coming in above industry standards and we pride ourselves in providing a...
-
Derby, CT 06418, USA, United States Griffin Health Services Corporation Full timeMAIN FUNCTION: The CDI specialist is a clinically knowledgeable professional who is proficient in analyzing and interpreting medical record documentation and capable of tracking and trending their CDI program goals and objectives. This professional possesses knowledge of healthcare and coding regulations, as well as anatomy, physiology, pharmacology and...
-
EMERGENCY DEPARTMENT RN
7 days ago
Illinois, USA, United States RN Staff Full timeProvides direct and indirect patient care in the Emergency Department. Evaluates outcomes, consults with other specialists and ancillary departments as required and adjusts nursing care processes as indicated to ensure optimal patient care and flow through ER. Provides care that meets the psychosocial, physical and general aspects of care; meets the...
-
SD - RN ORTHO/NEURO/SURGICAL - RAPID CITY
5 days ago
South Dakota, USA, United States RN Staff Full timeJob DescriptionEssential Functions:Utilizes the ANA Nursing Process (2010) to perform the following functions:Collects comprehensive data pertinent to the Healthcare consumer s health and/or the situation.Analyzes the assessment data to determine the diagnosis or the issues.Identifies expected outcomes for a plan individualized to the Healthcare consumer of...
-
Cincinnati, OH 45217, USA, United States UC Health Full timeUC Health is hiring a full-time remote CDI Specialist for Corporate Coding Services.The Clinical Documentation Improvement Specialist will work with physicians to facilitate appropriate clinical documentation to ensure that the level of services and acuity of care are accurately reflected in the medical record. Conducts follow-up reviews to ensure that...
