Clinical Documentation Registered Nurse RN - Hybrid

JOB SUMMARY 

Responsible for reviewing medical records to facilitate and obtain appropriate physician documentation for any clinical conditions or procedures to support the appropriate severity of illness, expected risk of mortality, and complexity of care of the patient, by improving the quality of the physicians’ clinical documentation. Exhibits a sufficient knowledge of clinical documentation requirements, MS-DRG Assignment, and clinical conditions and/or procedures.

 Educates members of the patient care team regarding documentation guidelines, including the following: attending physicians, allied health practitioners, nursing, and case management.   

ESSENTIAL DUTIES AND RESPONSIBILITIES

Include the following. Others may be assigned.

1. Record Review: 

•Completes initial medical records reviews of patient records within 24-48 hours of admission for a specified patient population to: (a) evaluate documentation to assign the principal diagnosis, pertinent secondary diagnoses, and procedures for accurate MS-DRG assignment, risk of mortality and severity of illness; and (b) record in business partner designated CDI tool and/or host medical record system. 

•Conducts follow-up reviews of patients every 24-48 hours or as needed up through discharge to support assigned working MS-DRG assignment upon patient discharge, as necessary.

•Formulate physician queries regarding missing, unclear, or conflicting health record documentation by requesting and obtaining additional documentation within the health record, as necessary.

•Collaborates with providers, case managers, nursing staff and other ancillary staff regarding documentation and to resolve physician queries prior to discharge.  

2.CDI

•Communicates/Completes Clinical Documentation Integrity (CDI) activities and coding issues (lacking documentation, physician queries, etc.) for appropriate follow-up, provider education and DRG Miss-Match reconciliation.

•Assists with Provider education, rounding and communication regarding open queries for resolution. 

3. Professional Development:  Stays current with AHA Official Coding and Reporting Guidelines, CMS and other agency directives for ICD10-CM and PCS coding. Attends CDI Boot camp, CDI/coding trainings annually and quarterly for inpatient coding. Attends monthly education lecture series (MELS) and all CDI/coding assigned learn share modules as well as any additional required CDI education. 

4. Assist in training department staff new to CDI 

5. Performs other duties as assigned 

KNOWLEDGE, SKILLS, ABILITIES

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• CDI Specialist must display teamwork and commitment while performing daily duties
• Must demonstrate initiative and discipline in time management and medical record review.
• Travel may be required to meet the needs of the facilities.
• Proficient knowledge of disease pathophysiology and drug utilization
• Intermediate knowledge of MS-DRG classification and reimbursement structures
• Critical thinking, problem solving and deductive reasoning skills.
• Effective written and verbal communication skills
• Excellent computer skills including MS Word/Excel
• Knowledge of coding compliance and regulatory standards 
• Excellent organizational skills for initiation and maintenance of efficient workflow
• Regular and reliable attendance
• Capacity to work independently in facility on-site setting. 
• Capacity to work independently in a virtual office setting if required for specific assignment.
• Exhibit flexibility as needed to meet program needs.
• Understand and communicate documentation strategies.
• Recognize opportunities for documentation improvement.
• Formulate clinically, compliant credible queries. 
• Ability to successfully comply to robust auditing and CDI program monitoring
• Ability to apply coding conventions, official guidelines, and Coding Clinic advice to health record documentation.

Conifer requires its candidates, as applicable and as permitted by law, to obtain and provide confirmation of all required vaccinations and screenings prior to the start of employment. This may include, but is not limited to, the COVID-19 vaccination, influenza vaccination, and/or any future required vaccines and screenings.

EDUCATION / EXPERIENCE

Include minimum education, technical training, and/or experience required to perform the job.

• Preferred:  Acute Care nursing and/or Provider relevant experience
• Zero (0) to two (2) years CDI experience
• Two (2) plus years’ nursing experience – Medical/Surgical/Intensive Care and/or Case/Utilization Review
• Two (2) plus years’ Provider experience – Medical/Surgical/Intensive Care and/or Case/Utilization Review
• Graduate from a Nursing program, BSN, or graduate program; OR
• Graduate from Medical Doctor and/or Foreign Medical Doctor Program

CERTIFICATES, LICENSES, REGISTRATIONS

• Active state Registered Nurse license; OR 
• Graduate MD and/or FMD license
• Preferred:  CDIP or CCDS

PHYSICAL DEMANDS 

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Ability to sit for extended periods of time.
• Ability to stand for extended periods of time.
• Must be able to efficiently use computer keyboard and mouse.
• Good visual acuity

WORK ENVIRONMENT 

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

OTHER

• Must be able to travel as needed, not to exceed 10%.