Clinical Documentation Specialist (Registered Nurse) (11396)

Job Summary:           

• The CDI Specialist performs clinically based initial, concurrent, and retrospective review of inpatient medical records to evaluate documentation as it correlates to the utilization of acute care services.
• The CDI Specialist employs critical thinking skills to discern Physician documentation of care to accurately reflect patient severity of illness and risk of mortality
• Assumes the responsibility and accountability for improving the overall quality and completeness of clinical documentation to aid in compliant reimbursement for acute care services and in reporting quality of care outcomes.
• Provide ongoing training to physicians and serve as a subject matter expert for clinical documentation standards.

Education:

Associate of Science in Nursing (or equivalent experience in Clinical Documentation Excellence considered)

Required to obtain one of the following certifications once eligible:

• Certified Clinical Documentation Specialist by the Association of Clinical Documentation Integrity Specialists
• Clinical Documentation Improvement Professional by the American Health Information Management Association
• Certified Professional Coder by the American Academy of Professional Coders
• Certified Coding Specialist

Experience:

Minimum of three (3) years of acute care hospital nursing experience.

Two (2) years of Clinical Documentation Excellence experience in an acute care setting preferred

Additional Skills/Abilities:                
Analytical skills; strong computer skills; ability to multi-task; detail oriented; good written; oral and interpersonal communication skills; working knowledge of medical terminology and pharmacology.