Nurse CDI Specialist: Elevate Medical Records and Coding

Coinscapture; United States; Hybrid; USD 55,000 - 62,000; Full time

Job summary

Datavant is seeking a Clinical Documentation Quality Improvement (CDQI) Specialist to elevate medical record documentation accuracy and DRG-related coding quality. This on-site role in the United States focuses on inpatient records, collaboration with physicians, and adherence to AHA guidelines.

You will conduct reviews, educate clinicians, query missing information, and maintain production metrics while protecting patient confidentiality. A RN license and CDI certifications are required.

Qualifications

• 3+ years of CDI experience.
• 3+ years of clinical experience in an academic medical center.
• RN license with Bachelor's degree in Nursing.
• CDDS or CDIP certification required.
• Pass a CDI skills competency assessment.

Responsibilities

• Conduct timely, accurate, and complete documentation reviews for inpatient records.
• Collaborate with physicians to ensure reimbursement and clinical severity for DRG-based payer patients.
• Demonstrate understanding of complications, co-morbidities, severity of illness, risk of mortality, case mix index, secondary diagnoses, and procedure impact on DRG.
• Improve coding specificity by educating physicians on clear documentation throughout patient stays.
• Follow AHA guidelines and coding clinics for accurate coding and required documentation.
• Query physicians regarding missing, unclear, or conflicting health record documentation to obtain details.
• Maintain daily production logs for reviews and queries.
• Perform follow-up reviews to confirm recorded points of clarification in records.
• Ensure confidentiality of all files, documents, and records.
• Meet or exceed production and quality metrics.

Job description

Datavant is seeking a Clinical Documentation Quality Improvement (CDQI) Specialist to elevate medical record documentation accuracy and DRG-related coding quality. This on-site role in the United States focuses on inpatient records, collaboration with physicians, and adherence to AHA guidelines.

You will conduct reviews, educate clinicians, query missing information, and maintain production metrics while protecting patient confidentiality. A RN license and CDI certifications are required.