Document Improvement Specialist

2 days ago

Phoenix, AZ, United States Axelon Full-time

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Utilize clinical/nursing knowledge to improve the quality and completeness of clinical documentation.
Collaborate with physicians to ensure accuracy of clinical information in medical records.
Work with Coding to support appropriate severity of illness and risk of mortality.
Provide education to physicians and ancillary staff regarding documentation clarification.
Collaborate with hospital departments to support efforts that justify medical necessity, admission, and continuity of patient care.

Certification required: RN, CCDS
Minimum 5 years of current CDI experience.
Epic experience.
3M/Solventum encoder experience.
Current, valid AZ RN or LPN license or valid compact RN or LPN licensure for current state of practice; or certification as RHIA/RHIT/CCS/CCS-P/CPC/CIC/COC.
Minimum of three years of recent clinical nursing, coding, or clinical documentation experience.

Experience in Trauma, Burn, Peds, and NICU.
Strong critical thinking and communication skills.
Effective interpersonal skills to interact with providers.
Analytical skills to interpret medical record documentation and formulate appropriate provider queries.
Knowledge of anatomy, physiology, pathophysiology, pharmacology, AHA Coding Clinic, and AHIMA Query Practice Brief guidelines.
Ability to benchmark and analyze clinical documentation program performance.
Knowledge of MS and APR-DRG’s, DRG assurance, Coding, Revenue Cycle, and Midas.
Basic computer word processing skills.
Ability to read, write, and speak effectively in English.