Clinical Documentation Improvement Spec. (CDI)

BJC HealthCare (New); Missouri; On-site; USD 65,000 - 90,000; Full time

Benefits offered by this job

BJC Total Rewards

Job summary

Barnes-Jewish Hospital is seeking a Clinical Documentation Improvement Specialist to join our team in Missouri. Ideal candidates have CDI or critical care nursing experience and RN licensure.

The role focuses on improving documentation quality to support accurate DRG and patient severity assessment. The CDI Specialist will interact with physicians, review inpatient and outpatient records, and work with coding teams to ensure precise coding and compliant documentation.

Qualifications

• Candidate has CDI or critical care nursing background.
• RN license and nursing degree required at minimum.
• Experience with inpatient/outpatient medical records and coding workflows is a plus.

Responsibilities

• Review clinical documentation to accurately reflect severity of illness and complexity of care.
• Coordinate with physicians to obtain documentation for correct coding and DRG assignment.
• Monitor and query records to ensure timely and compliant documentation improvements.
• Collaborate with HIMS coding staff to reconcile working and final DRG and outcomes.

Skills

CDI knowledge

Nursing background

Education

Nursing Diploma/Associate's

RN License

Job description

Additional Information About the Role

Barnes Jewish Hospital is seeking a CDI Specialist to join our team!

Ideal applicants will have a background in CDI or critical care bedside nursing.

Overview

Barnes-Jewish Hospital at Washington University Medical Center is the largest hospital in Missouri and is ranked as one of the nation's top hospitals by U.S. News & World Report. Barnes-Jewish Hospital's staff is composed of full-time academic faculty and community physicians of Washington University School of Medicine, supported by a house staff of residents, interns, fellows and other medical professionals. Recognizing its excellence in nursing care, Barnes-Jewish Hospital was the first adult hospital in Missouri to be certified as a Magnet Hospital by the American Nurses Credentialing Center.

Preferred Qualifications

Role Purpose

The Clinical Documentation Improvement Specialist I (CDIS I) uses clinical and coding knowledge for conducting clinically based concurrent and retrospective reviews of both inpatient and outpatient medical records reviews to evaluate the clinical documentation of clinical services by identifying opportunities for improving the quality of medical record documentation. This position 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.

Responsibilities

• 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.
• Utilizes hospital coding code set, policies and procedures, federal and state coding reimbursement guidelines, and application of the Coding Clinic Guidelines to assign working diagnosis-related groups (DRG); review patient records throughout hospitalization that have been identified as focus DRG by regulatory agencies or the facility to ensure the codes are reported at the highest specificity.
• Initiates physician interaction when abnormal ancillary test findings, ambiguous, missing or conflicting information is in the medical record, through the physician query process and/or participation in rounding with the physicians by requesting additional documentation for correct coding and compliance necessary for accurate reflection of CMI, LOS, and optimal resource utilization.
• Partners with other healthcare disciplines and HIMS coding staff to ensure accuracy of diagnostic and procedural data and completeness of supporting documentation to reconcile the working and final DRG, severity of illness, risk of mortality and quality outcomes.
• Initiates medical record review within 24 to 48 hours of admission; sytematically monitors the targeted medical records within at least 48 hours (unless otherwise indicated) to determine compliance to established documentation standards; conducts follow-up reviews to ensure points of clarification have been addressed/documented in the medical record.
• BJC has determined this is a safety-sensitive position. The ability to work in a constant state of alertness and in a safe manner is an essential function of this job.

Minimum Requirements

Education

• Nursing Diploma/Associate's
• - Nursing

Experience

• 2-5 years
• - Nursing

Licenses & Certifications

• RN

Preferred Requirements

Education

• Bachelor's Degree
• - Nursing

Experience

• 5-10 years
• - Nursing

Supervisor Experience

• No Experience

Benefits and Legal Statement

BJC Total Rewards

At BJC we’re committed to providing you and your family with benefits and resources to help you manage your physical, emotional, social and financial well-being.

• Comprehensive medical, dental, vison, life insurance, and legal services available first day of the month after hire date
• Disability insurance* paid for by BJC
• Annual 4% BJC Automatic Retirement Contribution
• 401(k) plan with BJC match