Registered Nurse (RN) - Clinical Documentation Integrity Specialist I, Full-Time, Days
Prisma HealthInspire health. Serve with compassion. Be the difference.
Job Summary
The RN Clinical Documentation Improvement Specialist performs on-site medical record reviews, examining and assessing all patient documentation to ensure that all information including the illness diagnosis is accurate. This is accomplished by a concurrent and retrospective review of medical records. Responsible for the validation of diagnosis codes and the identification of missing diagnosis so that patient severity of illness is properly reflected in the medical record.Essential Functions
All team members are expected to be knowledgeable and compliant with Prisma Health's purpose: Inspire health. Serve with compassion. Be the difference.
Conducts concurrent medical record reviews of selected patient health records to address clarity, completeness, consistency and accuracy of clinical documentation.
Employs the query process as needed to provide accurate documentation reflective of patient's severity of illness, risk of mortality, comorbid conditions, length of stay, principal diagnosis, and present on admission (POA) status.
Completes the reconciliation process to ensure accurate coding reflective of patient's severity of illness, risk of mortality, comorbid conditions, length of stay, principal diagnosis, and present on admission (POA) status.
Develops and maintains supportive, collaborative relationships with providers and health care team members to include education and follow up.
Stay current with coding guideline changes, changes in treatment modalities, clinical disease indicators, and compliant query policies.
Serves as a resource for co-workers, providers, and other support departments (coding, case management, quality, nutrition, etc.)
Assigns a working DRG for health care team discharge planning and CDI use.
Performs other duties as assigned
Supervisory/Management Responsibilities
This is a non-management job that will report to a supervisor, manager, director or executive.
Minimum Requirements
Education - Associate degree in Nursing, Health Information Management, or related field of study
Experience - Two (2) years -adult medical/surgical/critical care/ER/PACU nursing coding or related experience
In Lieu Of
In lieu of the education and experience requirements noted above, the following combination of education, training and/or experience may be considered an equivalent substitution: MD/DO/PA/NP
Required Certifications, Registrations, Licenses
RHIA/RHIT/CCS/CIC/or Licensure in related field of study/ Holds a current RN compact/multistate license recognized by the NCSBN Compact State or is licensed to practice as an RN in the state the team member is working.
Knowledge, Skills and Abilities
Computer skills
Communication skills with ability to interact with providers.
General knowledge of IPPS, ICD10 Coding, MS-DRG/APR-DRG and HCPCS coding systems preferred
Work Shift
Day (United States of America)Location
CorporateFacility
7001 CorporateDepartment
70017540 Clinical Documentation IntegrityShare your talent with us! Our vision is simple: to transform healthcare for the benefits of the communities we serve. The transformation of healthcare requires talented individuals in every role here at Prisma Health.