CDI Nurse Specialist: Elevate Medical Record Quality

Datavant; Bismarck (ND); On-site; USD 45,000 - 50,000; Full time

Job summary

Datavant seeks a Clinical Documentation Quality Improvement Specialist to elevate medical record documentation by reviewing inpatient records, engaging with physicians, and ensuring accurate DRG-based coding. You will educate teams on documentation importance, maintain compliance with AHA guidelines, and drive production and quality metrics.

This is a part-time to full-time CDI-focused role with a meaningful impact on patient care.

Qualifications

• 3+ years of CDI experience.
• 3+ years of clinical experience in an academic medical center.
• RN license and Bachelor's degree in Nursing.
• CCDS or CDIP certification.
• Must pass a CDI skills competency assessment.
• Must be able to accommodate a minimum 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 experience

Education

Registered Nurse license

Bachelor's degree in Nursing

CCDS or CDIP certification

Job description

Datavant seeks a Clinical Documentation Quality Improvement Specialist to elevate medical record documentation by reviewing inpatient records, engaging with physicians, and ensuring accurate DRG-based coding. You will educate teams on documentation importance, maintain compliance with AHA guidelines, and drive production and quality metrics.

This is a part-time to full-time CDI-focused role with a meaningful impact on patient care.