Inpatient Clinical Documentation Integrity Specialist

Valleywise Health; Phoenix (AZ); Hybrid; USD 77,000 - 113,000; Full time

Job summary

Valleywise Health in Phoenix, AZ seeks an Inpatient Clinical Documentation Integrity Specialist to improve the quality and completeness of medical records through a multidisciplinary approach. This role emphasizes collaboration with physicians and coding teams to ensure accurate and complete documentation that supports the patient care journey.

The position requires a solid nursing background, experience with CDI processes, and certification timelines.

Qualifications

• Associate's degree in Nursing or Health Information Technology is required; Bachelor's preferred.
• Minimum 3 years of recent clinical nursing, coding, or documentation experience.
• CCDS certification must be obtained within 30 months of hire; AZ RN/LPN licensure required.

Responsibilities

• Improve clinical documentation quality and medical record accuracy.
• Collaborate with physicians and coding teams to ensure appropriate severity of illness and risk of mortality.
• Educate providers on documentation clarification and guidance.

Skills

Clinical nursing

Coding knowledge

Documentation expertise

Communication skills

Analytical thinking

Education

Associate's degree in Nursing

Associate's degree in Health Information Technology

Bachelor's degree preferred

Tools

3M Solventum encoder

Midas

Job description

Inpatient Clinical Documentation Integrity Specialist

We are looking for highly specialized nursing professionals to join our team. The Clinical Documentation Integrity Specialist uses clinical/nursing knowledge of documentation requirements to consistently improve the quality and completeness of clinical documentation of patient records using a multidisciplinary team process. Works collaboratively with physicians to ensure clinical information in the medical record is present and accurate. This position collaborates with Coding to support the appropriate severity of illness and risk of mortality. The Clinical Documentation Specialist (CDS) will interact with physicians and ancillary staff, providing education regarding documentation clarification. Works in collaboration with hospital departments to support efforts that justify medical necessity, admission, continuity of patient care, and other clinical documentation requirements.

While all qualified clinical backgrounds will be considered, it is a huge plus if you possess:

Experience as a Critical Care, Trauma, Pediatric, NICU, or Burn Registered Nurse (RN).

Hands-on experience using the 3M / Solventum encoder.

Proven experience working with APR DRGs, mortality reviews, and Hospital-Acquired Conditions (HACs) / Patient Safety Indicators (PSIs).

Annual Salary Range: $76,835.20 - $113,339.20

This position offers a hybrid work schedule with regular in-office attendance. Candidates must be within a commutable distance and comfortable working in a physical office setting on a weekly basis.

Qualifications

Education

Requires an Associate's degree in Nursing or Health Information Technology or a related field or an equivalent combination of training and progressively responsible experience that will result in the required specialized knowledge and abilities to perform the assigned work.

A Bachelor's degree in Nursing, Health Information Administration, or a related field is preferred.

Experience

Must have a minimum of three (3) years of recent clinical nursing, Coding, or clinical documentation experience that demonstrates an understanding of the required knowledge, skills, and abilities.

Specialized Training

Clinical documentation improvement specialist experience or training is preferred.

Certification/Licensure

Must possess a current, valid AZ RN or LPN license or valid compact RN or LPN licensure for the current state of practice or certification as a RHIA/RHIT/CCS/CCS-P/CPC/CIC/COC.

A Certified Clinical Documentation Specialist (CCDS) certification must be obtained within thirty (30) months of hire.

Knowledge, Skills, and Abilities

Requires exceptional critical thinking, communication skills, and a strong clinical knowledge base.

Must possess effective interpersonal skills to interact effectively with Providers.

Requires analytical skills to interpret medical record documentation and formulate appropriate Provider queries based on the need for increased documentation specificity to clarify, link or establish diagnoses, conditions, and procedures.

Must possess knowledge of a wide range of specialized disciplines, including a solid knowledge base in anatomy and physiology, pathophysiology, and pharmacology, and knowledge of the AHA Coding Clinic and AHIMA Query Practice Brief guidelines.

Requires the ability to benchmark and analyze clinical documentation program performance.

Must have knowledge of MS and APR-DRG's, DRG assurance, Coding, Revenue Cycle, and Midas.

Requires basic computer word processing skills (e.g., formatting, editing, printing, composing email, internet searches, etc.) to navigate through an electronic medical record using a computer successfully.

Requires the ability to read, write and speak effectively in English.

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