CDI RN Specialist
3 weeks ago
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.
- 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.
- 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 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.
- 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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