About the position
The Clinical Documentation Improvement Specialist (CDI) at Jupiter Medical Center plays a crucial role in enhancing the quality and completeness of clinical documentation. This position involves extensive collaboration with physicians, nursing staff, and coding personnel to ensure that the documentation accurately reflects the care provided to patients. The CDI is responsible for facilitating concurrent modifications to clinical documentation, which is essential for ensuring appropriate reimbursement based on the clinical severity and services rendered to patients, particularly those covered by Diagnosis Related Group (DRG) based payers such as Medicare and Medicaid. In this role, the CDI will review concurrent medical records for compliance, ensuring that documentation is complete and accurate regarding the severity of illness (SOI) and quality of care. The specialist will analyze health records to identify relevant diagnoses and procedures for distinct patient encounters, translating diagnostic phrases used by healthcare providers into coded form. This requires effective communication with healthcare providers to ensure that the documentation is accurately represented. The CDI will also remain informed about ongoing changes in federal and state regulations related to prospective payment systems, treatment modalities, and new procedures. This knowledge is vital for performing coding when physician documentation is vague or missing. Additionally, the specialist will assign the appropriate DRG after conducting a thorough review of the medical record, ensuring compliance with reimbursement standards. The position requires practicing autonomously within professional nursing standards and adhering to the ANA Code of Ethics and the Florida Nursing Practice Act. The CDI will strive for quality outcomes and innovative practices, participating in quality assurance and performance improvement initiatives. This role is integral to ensuring optimal patient outcomes and maintaining high standards of care within the hospital.
Responsibilities
- Collaborate with physicians, nursing staff, and coding personnel to improve documentation quality.
- Facilitate concurrent modifications to clinical documentation for accurate reimbursement.
- Support timely and complete documentation of clinical information for measuring outcomes.
- Communicate and educate clinical staff on effective clinical documentation practices.
- Review concurrent medical records for compliance, completeness, and accuracy.
- Analyze health records to identify relevant diagnoses and procedures for patient encounters.
- Translate diagnostic phrases into coded form and ensure accurate representation.
- Remain current on changes in federal and state regulations for prospective payment.
- Assign appropriate DRG after reviewing medical records.
- Participate in quality assurance and performance improvement initiatives.
Requirements
- Current RN licensure in the state of Florida.
- Bachelor of Science in Nursing (BSN) preferred.
- At least 2 years of acute care experience, preferably in critical care.
- 2 years of experience in clinical documentation preferred.
- Certifications such as CCDS, CDIP, CCM, RHIA preferred.
- Experience with Cerner & Claro (CDR2) software.
