Registered Nurse New

Job Title: Clinical Documentation Integrity RN or LPN

Job Summary:

The Clinical Documentation Improvement (CDI) RN or LPN leverages clinical and coding expertise to conduct concurrent and retrospective reviews of inpatient and outpatient medical records. The goal is to enhance the quality of clinical documentation, focusing on areas identified by CDI leadership, such as mortality reviews and PSI reviews.

Essential Functions:

• Review clinical documentation to accurately represent the severity of illness, risk of mortality, and complexity of care.
• Communicate review results to leadership, CDI Specialists, and other staff, recommending corrective actions.
• Conduct focused reviews in areas identified by CDI leadership.
• Develop and present ongoing education for CDI specialists and related departments on documentation trends and CDI practices.
• Educate physicians and healthcare providers on documentation trends and CDI practices.
• Evaluate CDI accuracy and standardize review findings.
• Identify trends, variances, and deficiencies using aggregated data.
• Monitor the effectiveness of concurrent medical record reviews and queries.
• Collaborate with CDI Director, HIMS coding, Quality, and Compliance to ensure accurate diagnostic and procedural data.
• Serve as a subject matter expert on CDI practices, coding rules, and regulations.
• Utilize hospital coding policies, federal and state guidelines, and Coding Clinic Guidelines to assign working DRG.
• Initiate physician interaction for additional documentation when necessary.
• Partner with HIMS coding staff to ensure accurate diagnostic and procedural data.

Minimum Requirements:

• Bachelor’s degree in Nursing
• Five years of progressively responsible clinical work experience.
• Three years of experience as a Clinical Documentation Improvement Specialist.
• Experience with MS-DRG and APR-DRG focused reviews.
• At least one year of supervisory experience (preferred).
• Experience with quality outcomes focused CDI reviews (preferred).

Licenses/Certifications:

• RN or LPN required.
• CCDS certification through ACDIS

This role is critical in ensuring the accuracy and quality of clinical documentation, which directly impacts patient care and compliance with regulatory standards.