CDI Nurse Specialist: Documentation Quality & Coding

Datavant; Oklahoma City (OK); On-site; USD 55,000 - 62,000; Full time

Job summary

Datavant is seeking a Clinical Documentation Quality Improvement (CDQI) Specialist to elevate the impact of medical record documentation, focusing on inpatient records and DRG accuracy. This role involves daily evaluations, collaboration with physicians and caregivers to ensure appropriate reimbursement and clinical severity, and adherence to AHA guidelines for compliant coding.

You will maintain confidentiality, track production and quality metrics, and contribute to higher quality healthcare

Qualifications

• 3+ years of CDI experience
• 3+ years clinical experience in an academic medical center
• Registered Nurse license and Bachelor's degree in Nursing
• CCDS or CDIP certification
• Must pass a CDI skills competency assessment

Responsibilities

• Conduct timely, accurate, and complete documentation reviews for selected inpatient records, addressing inadequate or conflicting documentation.
• Collaborate with physicians and caregivers to ensure appropriate reimbursement and clinical severity for DRG-based payer patients.
• Demonstrate understanding of complications, co-morbidities, severity of illness, risk of mortality, case mix index, secondary diagnoses, and procedure impact on DRG.
• Improve coding specificity by educating physicians and caregivers on the importance of clear documentation throughout a patient's stay.
• Follow AHA guidelines and coding clinics for accurate coding and required documentation to ensure compliance.
• Query physicians regarding missing, unclear, or conflicting health record documentation to obtain necessary details.
• Maintain daily production logs for evaluation, tracking cases reviewed, queries placed/responded, etc.
• Perform follow-up reviews to confirm recorded points of clarification in the patient's medical record.
• Ensure confidentiality of all files, documents, and records.
• Meet or exceed production and quality metrics.

Skills

CDI experience

Clinical experience

Education

Registered Nurse license

Bachelor's degree in Nursing

CCDS or CDIP certification

Job description

Datavant is seeking a Clinical Documentation Quality Improvement (CDQI) Specialist to elevate the impact of medical record documentation, focusing on inpatient records and DRG accuracy. This role involves daily evaluations, collaboration with physicians and caregivers to ensure appropriate reimbursement and clinical severity, and adherence to AHA guidelines for compliant coding.

You will maintain confidentiality, track production and quality metrics, and contribute to higher quality healthcare