Healthcare Documentation Specialist

7 days ago


Bismarck, North Dakota, United States Tenet Healthcare Corporation Full time

About the Role:

This exciting opportunity is available within the Tenet Healthcare Corporation, a leading provider of healthcare services. As a CDI RN Specialist, you will play a critical role in ensuring the accurate and timely documentation of patient information.

Job Summary:

The CDI RN Specialist is responsible for reviewing medical records to facilitate and obtain appropriate physician documentation for any clinical conditions or procedures. This involves improving the quality of the physicians' clinical documentation, exhibiting knowledge of clinical documentation requirements, MS-DRG Assignment, and clinical conditions or procedures.

Key Responsibilities:

  • Record Review: Completes initial medical records reviews of patient records within 24-48 hours of admission to evaluate documentation and assign the principal diagnosis, pertinent secondary diagnoses, and procedures for accurate MS-DRG assignment.
  • Follow-up Reviews: Conducts follow-up reviews of patients every 2-3 days to support and assign a working or final MS-DRG assignment upon patient discharge.
  • Physician Queries: Formulates physician queries regarding missing, unclear, or conflicting health record documentation by requesting and obtaining additional documentation within the health record.
  • Collaboration: Collaborates with case managers, nursing staff, and other ancillary staff regarding interaction with physicians regarding documentation and to resolve physician queries prior to discharge.
  • Training: Assists 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.
  • Other Duties: Performs other duties as assigned.

Requirements:

  • Active state Registered Nurse license.
  • Preferred: CDIP or CCDS certification.
  • Ability to sit for extended periods and efficiently use a computer keyboard and mouse.
  • Good visual acuity.

Salary: $63,500 - $85,000 per year, depending on experience.



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