Clinical Documentation Integrity Specialist RN
Clinical Documentation Integrity Specialist RN
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Salary Not Disclosed
1 Vacancy
Job Description
Overview
Were seeking a Clinical Documentation Integrity Specialist (CDIS) RN to join our team! In this role youll be responsible for performing concurrent review of medical records to ensure complete and accurate clinical documentation to support severity of illness risk of mortality for outcomes reporting and for hospital reimbursement. The position requires a strong attention to detail and process orientation and an ability to think globally about documentation requirements in the medical records. The CDS must communicate effectively in oral and written form to physicians and other clinicians to promote accurate and complete documentation during the patients course of care. CDS supports the hospitals overall compliance efforts designed to ensure the accuracy of diagnosis and procedural coding Diagnosis Related Group (DRG) assignment severity of illness (SOI) and expected risk of mortality (ROM).
This position is remote/work from home and must be within 60 miles of a UnityPoint health affiliate in IL IA or WI.
PLEASE NOTE: This position is subject to prehire testing.
Why UnityPoint Health
- Commitment to our Team For the third consecutive year were proud to be recognized as a Top 150 Place to Work in Healthcare by Beckers Healthcare for our commitment to our team members.
- Culture At UnityPoint Health you matter. Come for a fulfilling career and experience a culture guided by uncompromising values and unwavering belief in doing whats right for the people we serve.
- Benefits Our competitive Total Rewards program offers benefits options that align with your needs and priorities no matter what life stage youre in.
- Diversity Equity and Inclusion Commitment Were committed to ensuring you have a voice that is heard regardless of role race gender religion or sexual orientation.
- Development We believe equipping you with support and development opportunities is an essential part of delivering a remarkable employment experience.
- Community Involvement Be an essential part of our core purposeto improve the health of the people and communities we serve.
Visit to hear more from our team members about why UnityPoint Health is a great place to work.
Why UnityPoint Health
At UnityPoint Health you matter. Were proud to be recognized as a Top 150 Place to Work in Healthcare by Beckers Healthcare several years in a row for our commitment to our team members.
Our competitive Total Rewards program offers benefits options that align with your needs and priorities no matter what life stage youre in. Here are just a few:
- Expect paid time off parental leave 401K matching and an employee recognition program.
- Dental and health insurance paid holidays short and longterm disability and more. We even offer pet insurance for your fourlegged family members.
- Early access to earned wages with Daily Pay tuition reimbursement to help further your career and adoption assistance to help you grow your family.
With a collective goal to champion a culture of belonging where everyone feels valued and respected we honor the ways people are unique and embrace what brings us together.
And we believe equipping you with support and development opportunities is a vital part of delivering an exceptional employment experience.
Find a fulfilling career and make a difference with UnityPoint Health.
Responsibilities
Operational:
- Conducts reviews of designated medical records to facilitate the creation of a health record that accurately represents the acuity of the patients illness and the resources used to treat the patient by ensuring provider documentation supports all applicable diagnosis codes.
- Ensures assignment of the working DRG is supported by diagnostic and procedural findings from the medical record. This will include the identification of secondary diagnosis that may result in Complications and Comorbidities (CC) and/or Major Complications and Comorbidities (MCC) assignment.
- Utilizes a compliant query process per guidelines and policies and follows each query through closure including complete documentation of ongoing follow up and communication.
- Maintains integrity and compliance of medical record reviews clinical documentation integrity documentation and queries.
- Efficiently and effectively utilizes UnityPoint Healths selected CDI software and processes (i.e. CDI worksheet and workflow physician query query and DRG reconciliation processes).
- Meets the minimum productivity and quality assurance standards established by the CDI department.
Relationship Building/Collaboration:
- Collaborates with coding staff and leaders for improved knowledge and understanding of coding guidelines.
- Collaborates with physicians and/or other hospital staff to coordinate work and resolve issues.
- Collaborates with Clinical Documentation Integrity leaders to provide feedback and receive work direction.
- Collaborates with other hospital departments as needed and directed by CDI leaders.
Qualifications
Education:
- RN
- BSN or higher preferred
Experience:
- Five 5 years of fulltime adult acute care RN experience in med/surg critical care emergency or Utilization review.
- Previous experience in clinical documentation improvement is preferred.
- Previous experience with chart review or chart auditing is preferred.
- Knowledge of ICD CM/PCS coding guidelines
License(s)/Certification(s):
Registered Nurse licensure required
Certified Clinical Documentation Specialist (CCDS) preferred
Certified Documentation Improvement Practitioner (CDIP) preferred
Knowledge/Skills/Abilities:
- Excellent interpersonal and communication skills
- Knowledge of reimbursement systems federal state and payer specific regulations and policies pertaining to documentation and coding
- Multicultural sensitivity
- Microsoft Office basic computer skills
- Customer/patient focused
- Critical thinking skills using independent judgment in making decisions
- Action Planning
- Ability to work independently
- Highly motivated selfstarter who works effectively with minimum supervision
- Ability to organize work quickly and efficiently and be comfortable working against deadlines
- Maintain effective working relationships
Required Experience:
Unclear Seniority
Employment Type
Full-Time
