Registered Nurse Clinical Documentation Integrity Specialist - Inpatient

Tucson Medical Center; Tucson (AZ); Hybrid; USD 90,000 - 110,000; Full time

Benefits offered by this job

Sign-on bonus

Job summary

Tucson Medical Center seeks an experienced RN Clinical Documentation Integrity Specialist to perform concurrent reviews of inpatient records, ensuring accurate diagnoses and appropriate level of care. You will query physicians when needed and collaborate with coding/HIM/UR to reflect patient acuity.

Requirements include a nursing degree, Arizona RN licensure, and 3 years of acute care RN experience; CDI experience is preferred.

Qualifications

• Graduation from a qualified nursing program.
• Minimum 3 years RN clinical experience in an acute care setting; CDI experience preferred.
• Current Arizona RN licensure; CCDS or CDIP preferred.

Responsibilities

• Conduct concurrent inpatient reviews to clarify documentation for acuity and level of care.
• Build rapport with providers to obtain clarifying documentation and follow up on queries.
• Educate physicians on documentation importance during meetings.
• Use management data to identify areas for improvement and actions.
• Uphold TMCH values and safety standards; perform related duties as assigned.

Skills

Clinical knowledge

Critical thinking

Age-specific care

Communication skills

Assertive communication

Admission criteria

Independent work

Mobility (standing/walking)

Education

Nursing degree

Job description

Registered Nurse Clinical Documentation Integrity Specialist - Inpatient

Job Category: Nursing

Schedule: Full time

Shift: 1 - Day Shift

Seeking Experienced RN Clinical Documentation Integrity Specialists.

$5,000 Sign On Available

SUMMARY

Provides concurrent review of the clinical documentation in the medical record; review the medical record with a clinical lens to identify any missing or understated diagnoses. Queries the medical staff when necessary, by written and/or verbal communication to obtain accurate and complete physician documentation that supports the patient condition(s) and treatment plan. Performs a thorough chart review to determine the appropriate principal diagnosis of the patient. Coordinates with coding/HIM/UR and other departments to achieve a record that reflects the acuity of the patient and level of care provided.

ESSENTIAL FUNCTIONS

• Conducts initial and follow-up concurrent reviews on inpatient admissions for opportunities to clarify documentation in the medical record for accurate reflection of the acuity of the patient and justifying the level of care. Documents findings in workflow tools, noting all key information used in the tracking process. Review medical record concurrently for documentation not yet in the record but supported by clinical indicators.
• Uses relationship building and strong communication skills to develop a rapport with providers to clarify information in the medical record.Uses appropriate querying templates to get needed documentation.Conducts follow-up on unanswered queries during the patient stay to obtain a response to unanswered queries.
• Provides education to physicians on the importance of complete documentation and key documentation concepts during regular physician meetings or on individually with physicians.
• Use data provided by managers, directors, and consulting team to actions to identify what is working well and areas of focus.
• Adheres to and support team members in exhibiting TMCH values of integrity, community, compassion, and dedication.
• Adheres to TMC organizational and department-specific safety, confidentiality, values, policies and standards.
• Performs related duties as assigned.

MINIMUM QUALIFICATIONS

EDUCATION: Graduation from a qualified, nationally-accredited nursing program.

EXPERIENCE: Three (3) years of RN clinical experience in an acute care setting. CDI experience preferred.

LICENSURE OR CERTIFICATION: Current RN licensure permitting work in state of Arizona. CCDS (Certified Clinical Documentation Specialist) from ACDIS or CDIP (Certified Documentation Improvement Practitioner) from AHIMA preferred.

KNOWLEDGE, SKILLS AND ABILITIES

• Extensive clinical knowledge and understanding of pathology/physiology; best demonstrated by clinical experience in hospital setting.
• Strong critical thinking skills and the ability to review the medical record to identify information not yet documented but supported by clinical indicators or clinical clues.
• Knowledge of age-specific patient needs and the elements of disease processes and related procedures.
• Excellent written and verbal communication skills; ability to write concisely and effectively when communicating with providers.
• Assertive personality traits to facilitate ongoing physician communication.
• Working knowledge of inpatient admission criteria.
• Ability to work independently in a time-oriented environment.
• Ability to stand and walk in the performance of job responsibilities.

D Demonstrates knowledge of the importance of, and makes an effort to capture, all appropriate secondary diagnoses for quality rating purposes.