Clinical Documentation Improvement Spec. (CDI)

BJC HealthCare; St. Louis (MO); On-site; USD 65,000 - 90,000; Full time

Benefits offered by this job

Medical, dental, vision insurance

401(k) plan with match

Disability insurance

Job summary

Barnes-Jewish Hospital seeks a Clinical Documentation Improvement Specialist I to enhance documentation quality and coding accuracy for inpatient and outpatient records. The role emphasizes physician collaboration and timely chart reviews to reflect illness severity and resource use.

The ideal candidate will have a CDI or critical care nursing background, RN licensure, and experience with hospital coding guidelines and DRG management.

Qualifications

• CDI or critical care nursing background preferred.
• RN licensure required with nursing education background.

Responsibilities

• Reviews documentation to improve severity of illness and accuracy of DRG and LOS.
• Uses coding guidelines to assign DRGs and ensure reporting at highest specificity.
• Initiates physician queries and rounds to obtain necessary documentation.
• Partners with HIMS and other disciplines to reconcile data and outcomes.
• Performs chart reviews within 24–48 hours, with follow-up to address gaps.
• This is a safety-sensitive position requiring constant alertness.

Skills

CDI knowledge

Critical care nursing

Education

Nursing Diploma/Associate's

Bachelor's Degree (Preferred)

Tools

RN

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