Clinical Documentation Improvement Nurse (RN)

Memorial Health; Springfield (IL); On-site; USD 49,593 - 78,523; Full time

Job summary

Memorial Health is seeking a Clinical Documentation Specialist to improve medical records documentation accuracy. The role involves concurrent and retrospective chart reviews, DRG assignments, and physician queries to support appropriate reimbursement.

The ideal candidate has 3–5 years of acute care or home health nursing experience, an Illinois RN license, BSN preferred, and CCDS preferred. Strong communication and collaboration with HIM Coding are essential.

Qualifications

• BSN preferred.
• Current RN licensure in the State of Illinois required.
• Certified Clinical Documentation Specialist (CCDS) preferred.
• Minimum of 3-5 years of recent acute care or home health nursing experience required.
• Experience in assigning DRGs based on clinical documentation to facilitate reimbursement.

Responsibilities

• Completes thorough chart review for identified inpatient accounts, assigns working DRG and alternative DRG if appropriate at admission.
• Reviews clinical documentation to improve accuracy of severity of illness, risk of mortality, and care complexity.
• Documents CC/MCCs appropriately to reflect potential diagnoses.
• Initiates physician queries to resolve missing or conflicting information.
• Conducts follow-up reviews to ensure clarifications are recorded in the chart.
• Consults physician advisor when indicated by reviews or query responses.
• Partners with HIM Coding staff to ensure data accuracy and documentation completeness.
• Uses HIM Coding feedback for self-improvement and discusses concerns with manager.
• Provides support as a clinical resource to HIM Coding Team.
• Participates in education regarding regulatory and payor requirements for documentation and reimbursement optimization.
• Implements staff and physician education on documentation initiatives.
• Implements quality improvement activities related to clinical documentation.
• Serves as a resource for managers, staff, and physicians on reporting standards and regulatory requirements.
• Adheres to Memorial Behavioral Standards.
• Participates in weekend coverage schedule.
• Assists with departmental data collection and analysis as needed.
• Performs other duties as assigned.

Skills

Communication skills

Clinical documentation knowledge

Query process understanding

Education

RN licensure in Illinois

BSN

CCDS certification preferred

Job description

Clinical Documentation Specialist

Salary: USD $35.92/hr – USD $57.47/hr.

Overview

The Clinical Documentation Specialist is responsible for improving the overall integrity of medical records documentation. The CDI Specialist uses clinical and coding knowledge to conduct clinically based concurrent and retrospective chart reviews to evaluate the clinical documentation of clinical services by identifying opportunities for improving timely, accurate and completeness of medical record documentation. Facilitates and obtains appropriate physician documentation for any clinical conditions or procedures to support the appropriate severity of illness, expected risk of mortality, and complexity of care of the patient. The Clinical Documentation Improvement Specialist plays a significant role in optimizing appropriate reimbursement for acute care services.

Education

BSN preferred.

Licensure / Certification / Registry

Current RN licensure in the State of Illinois required. Certified Clinical Documentation Specialist (CCDS) preferred.

Experience

Minimum of 3-5 years of recent acute care or home health nursing experience required. Previous clinical documentation experience strongly preferred with experience in assigning DRGs based on clinical documentation to facilitate reimbursement from admissions, and preparing supporting correspondence or appeal letters as needed.

Other Knowledge / Skills / Abilities

Understanding of healthcare reimbursement mechanisms preferred. Strong oral and written communication skills. Understanding of the principles of performance improvement, team collaboration, and conflict resolution. Evidence of continuing professional development.

Responsibilities

• Completes thorough chart review for all identified inpatient accounts, assigns working DRG and alternative DRG if appropriate at time of admission.
• Reviews clinical documentation to facilitate the accurate representation of the severity of illness, expected risk of mortality, and complexity of care by improving the quality of the physician’s clinical documentation.
• Demonstrates an understanding of the importance of accurate documentation to capture all potential secondary diagnoses for accuracy and quality purposes, documents all identified CC/MCC’s appropriately.
• Initiates physician interaction when ambiguous, missing, or conflicting information is in the medical record, through the physician query process through verbal or written channels for documentation clarification requests.
• Conducts follow up reviews of clinical documentation to ensure points of clarification have been recorded in the patient’s record.
• Consults physician advisor when indicated by clinical review results or lack of query response for significant reportable condition or question of clinical validation.
• Partners with HIM Coding staff to ensure accuracy of diagnostic and procedural data and completeness of supporting documentation to determine final DRG, severity of illness, risk of mortality and quality outcomes.
• Utilizes HIM Coding feedback on completed documentation as a means of continuous self-evaluation; discusses identified feedback concerns with manager.
• Provides support and serves as a clinical resource to HIM Coding Team.
• Participates in ongoing education regarding regulatory (e.g. OIG, Medicare, JCAHO) and payor requirements for clinical documentation aspects of utilization management, compliance, and reimbursement optimization.
• Implements staff and physician education regarding clinical documentation initiatives.
• Implements quality improvement activities regarding clinical documentation issues.
• Serves as a resource for department managers, staff and physicians to obtain information or clarification on accurate and ethical reporting and documentation standards, guidelines, and regulatory requirements.
• Demonstrates adherence to Memorial Behavioral Standards.
• Participates in weekend coverage schedule.
• Assists with departmental data collection and analysis as needed.
• Performs other duties as assigned.