RN-Clinical Documentation Specialist, Level 2 Reviewer

About the position

The Clinical Documentation Improvement (CDI) Specialist plays a crucial role in ensuring the accuracy and completeness of medical records, which reflect the current health status of patients. This position involves collaboration with interdisciplinary care teams to enhance clinical documentation, improve risk-adjusted scores, and ensure compliance with regulatory requirements. The CDI Specialist is responsible for conducting reviews of clinical records, providing education to clinical staff, and identifying opportunities for program development and process improvements.

Responsibilities

• Reviews clinical records for clinical documentation integrity and mortality scoring.
• Collaborates with others regarding clinical documentation improvement (CDI) and risk adjustment findings.
• Maintains knowledge of Centers for Medicare and Medicaid Services (CMS) requirements related to clinical documentation and provides feedback to clinical staff during concurrent record reviews.
• Maintains knowledge of mortality models, observed rate/expected rate (O/E ratios), industry trends, and diagnosis review group (DRG) frequency.
• Serves as a liaison between coding staff and physicians, identifying opportunities for new program development or program extensions.
• Works with team members on opportunities for improvement in standard work.
• Maintains documentation logs for adjusted risk and CDI opportunities.
• Applies evidence-based practice and scientific knowledge in healthcare to nursing practice, ensuring age-specific and clinical needs are met.
• Works in a constant state of alertness and safe manner.
• Performs other duties as assigned.

Requirements

• Bachelor's Degree in Nursing preferred.
• Two years of CDI experience required.
• Three to five years of acute inpatient care experience preferred.
• Mortality and PSI review experience preferred.
• Epic and Vizient experience preferred.
• Graduate of an accredited school of nursing, PA, NP, or medical school, or Associate's degree with Certified Clinical Documentation Specialist (CCDS) certification.

Nice-to-haves

• Experience in clinical documentation with a Certified Clinical Documentation Specialist (CCDS) certification.

Benefits

• Health insurance
• 401k retirement plan
• Paid time off
• Flexible scheduling options
• Professional development opportunities