CDI RN Specialist | Clinical Documentation Integrity

4 weeks ago

Washington, United States Children's National Full time

Minimum Education

BSN (Required)

Minimum Work Experience

5 years Experience with at least 3 years in clinical nursing. (Required)

Functional Accountabilities
Professional Practice/Research


Participate in Shared Leadership.


Contribute to the MAGNET Journey of Children’s National.


Ensure that nursing practice is based on evidence of best practices.


Accountable to participate in the Nursing Division’s Performance Improvement process (division or unit level).


Participate in community activities.
Clinical Documentation


Provide daily clinical evaluation of the medical record including physician and clinical documentation, lab results, diagnostic information, and treatment plans.


Collaborate with Coder CDI Specialist in regard to interaction with physicians on documentation, and to resolve physician queries prior to patient discharge.


Communicate with physicians (face-to-face or via clinical documentation inquiry forms) regarding missing, unclear, or conflicting medical record documentation; work with providers to ensure accurate and complete documentation is in the patient record.


Apply nationally recognized criteria to support physician queries; address delays in closing of physician queries with the appropriate departmental and leadership individuals.


Coordinate daily evaluation of documentation by the medical staff and/or healthcare team in accordance with Children’s National policies and procedures.
Program Activities


Target activities to specific payers, DRGs, and teams based on financial and clinical data analysis.


Collect and analyze data on program efforts and outcomes; identify patterns, trend variances, and opportunities to improve documentation review and process.


Assist in the development and reporting of performance measures to the medical staff and/or healthcare teams; prepare physician specific data reports.


Ability to follow-up on previous cases reviewed and prioritize work.


Facilitate change process required to capture needed documentation such as template/forms design.


Develop physician/provider education strategies to promote complete and accurate clinical documentation and correct negative trends.
Communicate


Communicate verbally with physicians and/or healthcare team in a clear, timely, accurate, and professional manner.


E-mail communication conveys clear, timely, accurate, and pertinent information in an organized professional format.
Performance Improvement


Ensure all physician queries are in compliance with federal regulations.


Identify opportunities for system-wide documentation improvement activities.


Promote the development of accurate and complete clinical documentation with physicians and other members of the healthcare team.


Active participation on departmental and/or hospital committees as assigned.


Educate members of the patient care team regarding specific documentation needs; education team members about reporting and reimbursement issues identified through concurrent/ retrospective documents review and aggregate data analysis.

Organizational Accountabilities
Organizational Accountabilities (Staff)
Organizational Commitment/Identification

Anticipate and responds to customer needs; follows up until needs are met


Teamwork/Communication

Demonstrate collaborative and respectful behavior


Partner with all team members to achieve goals


Receptive to others’ ideas and opinions


Performance Improvement/Problem-solving

Contribute to a positive work environment


Demonstrate flexibility and willingness to change


Identify opportunities to improve clinical and administrative processes


Make appropriate decisions, using sound judgment


Cost Management/Financial Responsibility

Use resources efficiently


Search for less costly ways of doing things


Safety

Speak up when team members appear to exhibit unsafe behavior or performance


Continuously validate and verify information needed for decision making or documentation


Stop in the face of uncertainty and takes time to resolve the situation


Demonstrate accurate, clear and timely verbal and written communication


Actively promote safety for patients, families, visitors and co-workers


Attend carefully to important details - practicing Stop, Think, Act and Review in order to self-check behavior and performance

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