Registered Nurse Clinical Documentation Integrity Specialist

SUMMARY:

Works with physicians, HIM (Health Information Management), ancillary staff, and multidisciplinary team members to improve the quality, and completeness of documentation of the patient’s clinical condition and treatment provided for designated populations. Provides timely and concurrent review of clinical documentation to facilitate the improvement of documentation within the medical record to accurately reflect appropriate SOI (Severity of Illness), ROM (Risk of Mortality), and DRG (Diagnostic Related Group) assignment. Clarifies documentation by querying the medical provider via electronic or verbal communication.

ESSENTIAL FUNCTIONS:

Identifies patients meeting criteria for review and provides a timely concurrent review of the clinical record.

Reviews medical records to identify the principal diagnosis and working DRG.

Collaborates and communicates with medical providers, HIM (Health Information Management), Interdisciplinary Team, and ancillary staff.

Documents in a clear, complete, concise, and organized manner using EPIC and 3M software.

Reviews and monitors cases for variance between ALOS (Average Length of Stay) and GMLOS (Geometric Mean Length of Stay).

Coordinates and collaborates with HIM/Coders via CDI/Coder meetings, weekly retrospective reviews, and case by case as needed.

Analyzes current data, operations, policies, systems, procedures, and develops and implements necessary and innovative changes.

Participates in ongoing professional development to stay current with changes in the industry as required.

Exhibits excellence in customer service through professional attitude and interaction with providers and staff.

Exemplifies and encourages TMCH values of integrity, community, compassion, and dedication within the workgroup and in the wider organization. 

Adheres to TMC organizational and department-specific safety, confidentiality, values policies and standards.

Assists with program planning, development, education, and evaluation.

Participates and encourages ongoing provider, staff, and colleague continuing education regarding changes in coding guidelines and documentation needs.

Assists in promoting quality care by concurrently identifying and referring all potential quality/compliance issues to the appropriate department.

Promote and maintain the code of ethics established by the Association of Clinical Documentation Improvement Specialist (ACDIS) and American Health Information Management Association (AHIMA).

Performs related duties as assigned.

RN CDI Second-Level Reviewer

Works with physicians, HIM (Health Information Management), CDI team members, ancillary staff, and multidisciplinary team members to improve the quality, and completeness of documentation of the patient’s clinical condition and treatment provided for designated populations. Provides second-level reviews of clinical documentation of concurrent and retrospective documentation as it relates to Patient Safety Indicators (PSI), Hospital Acquired Conditions (HAC), payer denials, working DRG and final DRG mismatches, and mortality reviews, and other appropriate second levels. The second-level reviews will validate the working and/or final DRG to ensure the appropriate assignment of SOI (Severity of Illness), ROM (Risk of Mortality), and DRG (Diagnostic Related Group) assignment. Clarifies documentation by querying the medical provider via electronic or verbal communication. Collect data and produce reports as requested. Collaborates with Denial Management team throughout the appeal processes. Perform second-level reviews as directed by the RN CDI lead. Provide training to the CDI, Coding staff, and leadership an on updates to quality guidelines, and denial trends. Analyzes current data, operations, policies, systems, procedures, and develops and implements necessary and innovative changes.

MINIMUM QUALIFICATIONS

EDUCATION:  Bachelor's degree in nursing.

EXPERIENCE:  Three (3) years of Medical/Surgical nursing experience in an acute hospital setting.  CDI experience preferred.

LICENSURE OR CERTIFICATION: Current RN licensure permitting work in state of Arizona. CCDS (Certified Clinical Documentation Specialist) from ACDIS or CDIP (Certified Documentation Improvement Practitioner) from AHIMA preferred.

KNOWLEDGE, SKILLS AND ABILITIES: 

·         Strong working knowledge of all areas of adult medicine, anatomy and physiology as it relates to the acute hospital setting.

·         Excellent verbal and written communication skills.  Ability to communicate in a clear and concise manner with physicians and staff to ensure accurate documentation in the medical record.

·         Requires critical/analytical thinking and problem solving skills in evaluating clinical documentation.

·         Ability to read, analyze, and interpret general business periodicals, professional journals, technical procedures, or governmental regulations.

·         Ability to write reports, business correspondence, and procedure manuals.

·         Ability to effectively present information and respond to inquiries or complaints from physicians and ancillary staff in a positive, professional interpersonal manner.

·         Ability to calculate figures and compute rate, ratio, and percent and to draw and interpret bar graphs and apply basic algebraic concepts.

·         Ability to define problems, collect data, establish facts, and draw valid conclusions.

·         Ability to interpret an extensive variety of technical instructions in mathematical or diagram form and deal with several abstract and concrete variables.