Clinical Documentation Integrity Specialist

San Juan Regional Medical Center; United States; On-site; USD 70,000 - 100,000; Full time

Job summary

San Juan Regional Medical Center is seeking a Clinical Documentation Improvement (CDI) Specialist with a strong nursing background to review inpatient records for accuracy and coding alignment. The role collaborates with physicians, case management, and coding to close documentation gaps and improve DRG assignment.

The ideal candidate holds an active New Mexico RN license, has at least three years of acute care experience, and demonstrates excellent communication and analytical skills.

Qualifications

• Registered nurse with at least 3 years of acute care experience.
• Current New Mexico RN licensure.
• Excellent written and verbal communication skills.
• Strong analytical thinking and attention to detail.
• Team-oriented with solid organizational skills.
• Basic computer skills and ability to use documentation systems.

Responsibilities

• Comprehensively reviews patient records to assure accurate severity of illness representation.
• Assigns Working DRG and reviews documentation with physicians, case management, and coding.
• Identifies gaps in physician documentation and drives improvement interventions.
• Identifies CDI best practices and benchmarks to support compliance objectives.
• Stays current on coding, compliance, guidelines, and payer requirements related to MS-DRG.

Skills

CDI

Nursing

Analytical thinking

Team-oriented

Communication skills

Basic computer skills

Education

RN License (NM)

Job description

Creating Life Better Here starts with you. At San Juan Regional Medical Center, we're more than a healthcare provider—we're a values-driven organization dedicated to delivering exceptional care. As a team member, you help fulfill our mission to make life better here for our community. Facilitates improvement in the quality and completeness of patient records on a concurrent basis, using a multi-disciplinary process. Applies clinical knowledge and coding knowledge to evaluate clinical indicators, diagnoses, and treatment plan for assigned inpatients, to identify gaps in physician documentation.

Required Behaviors:

As you go about fulfilling this mission, your work habits and work relationships should embody SJRMC's values. These values are our culture, our identity as an organization: Sacred Trust, Personal Reverence, Thoughtful Anticipation, Team Accountability and Creative Vitality ask more of us than merely completing some list of tasks. Our values ask for a deeper level of commitment, and what is asked of us we freely give because we believe in our mission.

Required Qualifications:

• Registered Nurse - Minimum of three (3) years strong clinical background in acute care
• Current NM Licensure
• Excellent written and verbal communication skills
• Analytical thinking skills
• Team-oriented
• Basic computer skills
• Highly organized

Preferred Qualifications:

• BSN Certified Clinical Documentation Specialist (CCDS) Coding experience

Duties and Responsibilities:

• Comprehensively reviews patient records, concurrently and retrospectively, to assure a complete and accurate representation of the severity of illness and use of resources.
• Assigns Working DRG Works closely with physicians, Case Management staff, and Coding to review documentation coding practices analyzing whether documentation supports the acuity of the patients.
• Identifies gaps in physician documentation and facilitates appropriate documentation improvement interventions with physicians.
• Identifies Clinical Documentation Improvement (CDI) best practices, benchmarks and improvement strategies to augment compliance objectives.
• Stays current on information pertaining to coding, compliance, clinical guidelines and payer requirements as it relates to MSDRG assignment, documentation and other payment requirements.
• Each employee is responsible for implementing SJRMC's Service Standards into their daily work: Safety, Courtesy, Effectiveness, and Stewardship.
• Other duties as assigned.

Physical Demands and Environmental Work Conditions:

• Prolonged standing/sitting/walking
• Fast paced environment
• High level of activity with many interruptions
• Possible exposure to communicable disease
• Repetitive motions (i.e.; keyboard usage)

Sensory Requirements:

• Alarms on equipment/fire alarms/overhead announcements Patients/family/physician verbal discussion Feedback from other healthcare providers
• Focus on close-up and distant objects Have intact: peripheral vision and depth perception

As you go about fulfilling this mission, your work habits and work relationships should embody SJRMC's values. These values are our culture, our identity as an organization. Sacred Trust, Personal Reverence, Thoughtful Anticipation, Team Accountability and Creative Vitality ask more of us than merely completing some list of tasks. Our values ask for a deeper level of commitment, and what is asked of us we freely give because we believe in our mission.

To learn more, visit us at http://www.sanjuanregional.com.