Clinical Documentation Improvement Specialist RN

Overview:

Position is 100% remote. Must live in Ohio

Schedule: Monday-Friday (8a-5p), 40/hrs. week

Must be a RN for at least 10 years, with 5 years being in pediatrics. ICU and/or surgery experience preferred.

Job Description Summary:

Reviews inpatient medical records and identifies opportunities that will clarify patient severity of illness, risk of mortality, quality indicator measures, and intensity of care rendered. Collaborates with providers and HIM coding staff to ensure accurate clinical documentation and support diagnosis and clinical indicators in the medical record.

Job Description:

Essential Functions:

• Reviews clinical documentation to ensure accuracy and completeness.
• Collaborates with healthcare providers to clarify documentation and ensure appropriate coding.
• Educates healthcare providers on documentation best practices and coding guidelines.
• Analyzes data and identifies trends to improve documentation and coding processes.
• Develops and implements policies and procedures related to clinical documentation improvement.
• Maintains up-to-date knowledge of regulatory requirements and industry standards related to clinical documentation and coding.

Education Requirement:

Bachelors Degree in Nursing or MBBS designation, required.

Licensure Requirement:

Current RN license in the state of Ohio, required.

Certifications:

• Certification in health-related field or Clinical Documentation Improvement (RHIA, RHIT, CDIP), preferred.
• CDIP credential, preferred.

Skills:

• Critical reasoning skills in clinical decision-making, problem solving, and ability to interpret medical record data.
• Flexible, positive and clear interpersonal and communication skills with the ability to provide information in a collaborative manner with physicians and other staff.
• Knowledge of computer-based applications including but not limited to Word, Excel, 3M encoder, EHR (Epic).
• Organizational skills.
• Excellent written communication skills.

Experience:

• Five years of experience in inpatient medical/surgical or critical care setting, required.
• Ten years of experience in a pediatric inpatient medical/surgical or critical care setting, preferred.
• Two years of experience as a CDI Specialist, preferred.
• HIM Coding experience, preferred.
• Competency in ICD-10 documentation requirements, preferred.

Physical Requirements:

OCCASIONALLY: Climb stairs/ladder, Lifting / Carrying: 0-10 lbs, Lifting / Carrying: 11-20 lbs, Standing, Walking

FREQUENTLY: (none specified)

CONTINUOUSLY: Audible speech, Computer skills, Decision Making, Flexing/extending of neck, Hand use: grasping, gripping, turning, Hearing acuity, Interpreting Data, Problem solving, Repetitive hand/arm use, Seeing Far/near, Sitting

Additional Physical Requirements performed but not listed above:

(not specified)

"The above list of duties is intended to describe the general nature and level of work performed by individuals assigned to this classification. It is not to be construed as an exhaustive list of duties performed by the individuals so classified, nor is it intended to limit or modify the right of any supervisor to assign, direct, and control the work of employees under their supervision. EOE M/F/Disability/Vet"