Nurse CDI Specialist: Documentation & Coding Leader

Charleston Area Medical Center; Charleston (WV); On-site; USD 65,000 - 90,000; Full time

Job summary

Charleston Area Medical Center seeks a Registered Nurse CDI Specialist to evaluate patients' medical records for documentation accuracy. Uses coding guidelines to identify undocumented conditions and educates physicians to improve documentation for proper reimbursement.

This role supports the Coding & Data Registry in the Document Center Building in Charleston, WV, with a standard Days schedule and full-time status.

Qualifications

• Bachelor's Degree required; 5-7 years acute or critical care nursing experience.
• Substitution: Associate Degree in Nursing with 7-10 years acute/critical care nursing experience. May substitute for Bachelor's.

Responsibilities

• Read and interpret inpatient records to identify all diagnoses and procedures.
• Determine proper diagnostic and procedural sequencing per UHDDS guidelines.
• Comply with HCFA Medicare code edits.
• Use Code3 Encoder/Grouper to find opportunities for improved documentation.
• Educate physicians on accurate documentation of diagnoses and procedures.
• Ensure quality and accuracy of records for appropriate reimbursement.
• Verify and correct data discrepancies by communicating with physicians and staff.
• Participate in quality improvement processes.
• Promote positive customer service and a constructive work environment.

Education

Bachelor's Degree

Associate Degree in Nursing

Job description

Charleston Area Medical Center seeks a Registered Nurse CDI Specialist to evaluate patients' medical records for documentation accuracy. Uses coding guidelines to identify undocumented conditions and educates physicians to improve documentation for proper reimbursement.

This role supports the Coding & Data Registry in the Document Center Building in Charleston, WV, with a standard Days schedule and full-time status.