Pediatrics CDI Clinical Documentation Specialist

Nemours Children's Health; Orlando (FL); Sur place; USD 90 000 - 120 000; Plein temps

Résumé du poste

Nemours Children's Health in Orlando, FL seeks a Clinical Documentation Specialist to review and assure accurate pediatric medical record documentation for ICD-10 coding, DRG assignment, and quality reporting.

The CDI Specialist will collaborate with physicians, quality teams, and revenue cycle staff to improve documentation, develop tools, and deliver provider education, including risk stratification and documentation best practices for billing.

Qualifications

• RN licensed, active and unrestricted in DE or FL.
• CDI/coding certification preferred.
• Minimum 5 years pediatric nursing experience.
• Extensive knowledge of medical terminology, anatomy, physiology, pharmacology and disease processes.

Responsabilités

• Review inpatient medical records within 2 days of admission for documentation opportunities and problem list accuracy.
• Attend multidisciplinary patient rounds with care team.
• Query care team regarding documentation opportunities and ICD-10 specificity, and track responses in Epic.
• Design and implement tools and educational programs to support physician EHR documentation.
• Identify education needs for new providers soon after onboarding and develop offerings.
• Identify trends for documentation improvement and report to attending group in education sessions.
• Maintain expert knowledge of ICD-10 changes and educate providers accordingly.
• Understand DRG methodologies including APR DRG and MS DRG.
• Collaborate with hospital staff, coding integrity, physician champion and leaders to sustain improvements.

Connaissances

Clinical documentation improvement

Epic EHR

Medical terminology

Pediatric nursing

Communication with care team

Formation

Registered Nurse license

Pediatric nursing experience

CDI certification preferred

Outils

Epic

Description du poste

Nemours Children's Health in Orlando, FL seeks a Clinical Documentation Specialist to review and assure accurate pediatric medical record documentation for ICD-10 coding, DRG assignment, and quality reporting.

The CDI Specialist will collaborate with physicians, quality teams, and revenue cycle staff to improve documentation, develop tools, and deliver provider education, including risk stratification and documentation best practices for billing.