CDI Nurse Specialist - Elevate Documentation Quality

Datavant; Pierre (SD); On-site; USD 45,000 - 50,000; Full time

Job summary

Datavant is hiring a Clinical Documentation Quality Improvement (CDQI) Specialist to elevate medical record documentation and influence coding accuracy. You will perform daily evaluations and engage with providers to enhance clarity, completeness, and overall documentation quality across inpatient records.

You will collaborate with physicians to ensure appropriate DRG-based reimbursement, query missing details, and maintain daily production logs while upholding confidentiality and compliance.

Qualifications

• 3+ years of CDI experience.
• 3+ years of clinical experience in an academic medical center.
• Registered Nurse license, Bachelor's degree in Nursing.
• CCDS or CDIP certification required
• Must pass a CDI skills competency assessment
• Must be able to accommodate a min of 15 hours per week

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 nursing experience

RN license

CDDS/CDIP certification

Querying physicians

Documentation reviews

Education

Bachelor's degree in Nursing

RN license

Job description

Datavant is hiring a Clinical Documentation Quality Improvement (CDQI) Specialist to elevate medical record documentation and influence coding accuracy. You will perform daily evaluations and engage with providers to enhance clarity, completeness, and overall documentation quality across inpatient records.

You will collaborate with physicians to ensure appropriate DRG-based reimbursement, query missing details, and maintain daily production logs while upholding confidentiality and compliance.