Registered Nurse (RN) - CDI (Hybrid)

Conifer Health Solutions; Birmingham (AL); On-site; USD 65,000 - 85,000; Full time

Job summary

Conifer Health Solutions seeks a CDI Specialist to review medical records and enhance documentation quality. You will guide physicians on documentation requirements, perform timely record reviews, and collaborate with care teams to ensure accurate MS-DRG assignments and risk adjustment.

Ideal candidates have nursing training or provider experience, strong communication skills, and familiarity with CDI guidelines and coding practices. Travel may be required.

Qualifications

• CDI Specialist must have nursing background or provider experience.
• Experience with documentation guidelines, coding rules and MRD guidance is preferred.
• Ability to educate care teams on documentation standards.

Responsibilities

• Record review of medical records within 24-48 hours to support accurate MS-DRG assignment.
• Conduct follow-up reviews through discharge to support correct DRG and mortality risk.
• Formulate physician queries for missing or unclear documentation.
• Collaborate with providers, case managers and nursing staff on documentation.
• Assist in provider education and CDI education activities.

Skills

Nursing background

Clinical documentation

MS-DRG knowledge

Query formulation

Communication skills

Education

BSN or higher nursing degree

MD/Foreign MD

Tools

MS Word

MS Excel

Job description

Working location

Princeton Medical Center

Shift Information

Mon-Friday Days

Must live within 1hour of Birminham, AL

Job Summary

Responsible for reviewing medical records to facilitate and obtain appropriate physician documentation for any clinical conditions or procedures to support the appropriate severity of illness, expected risk of mortality, and complexity of care of the patient, by improving the quality of the physicians’ clinical documentation. Exhibits a sufficient knowledge of clinical documentation requirements, MS-DRG Assignment, and clinical conditions and/or procedures. Educates members of the patient care team regarding documentation guidelines, including the following: attending physicians, allied health practitioners, nursing, and case management.

Essential Duties And Responsibilities

• Record Review:


• Completes initial medical records reviews of patient records within 24-48 hours of admission for a specified patient population to: (a) evaluate documentation to assign the principal diagnosis, pertinent secondary diagnoses, and procedures for accurate MS-DRG assignment, risk of mortality and severity of illness; and (b) record in business partner designated CDI tool and/or host medical record system.


• Conducts follow-up reviews of patients every 24-48 hours or as needed up through discharge to support assigned working MS-DRG assignment upon patient discharge, as necessary.


• Formulate physician queries regarding missing, unclear, or conflicting health record documentation by requesting and obtaining additional documentation within the health record, as necessary.


• Collaborates with providers, case managers, nursing staff and other ancillary staff regarding documentation and to resolve physician queries prior to discharge.


• CDI


• Communicates/Completes Clinical Documentation Integrity (CDI) activities and coding issues (lacking documentation, physician queries, etc.) for appropriate follow-up, provider education and DRG Miss-Match reconciliation.


• Assists with Provider education, rounding and communication regarding open queries for resolution.


• Professional Development: Stays current with AHA Official Coding and Reporting Guidelines, CMS and other agency directives for ICD10-CM and PCS coding. Attends CDI Boot camp, CDI/coding trainings annually and quarterly for inpatient coding. Attends monthly education lecture series (MELS) and all CDI/coding assigned learn share modules as well as any additional required CDI education.


• Assist in training department staff new to CDI


• Performs other duties as assigned

Knowledge, Skills, Abilities

• CDI Specialist must display teamwork and commitment while performing daily duties


• Must demonstrate initiative and discipline in time management and medical record review.


• Travel may be required to meet the needs of the facilities.


• Proficient knowledge of disease pathophysiology and drug utilization


• Intermediate knowledge of MS-DRG classification and reimbursement structures


• Critical thinking, problem solving and deductive reasoning skills.


• Effective written and verbal communication skills


• Excellent computer skills including MS Word/Excel


• Knowledge of coding compliance and regulatory standards


• Excellent organizational skills for initiation and maintenance of efficient workflow


• Regular and reliable attendance


• Capacity to work independently in facility on-site setting.


• Capacity to work independently in a virtual office setting if required for specific assignment.


• Exhibit flexibility as needed to meet program needs.


• Understand and communicate documentation strategies.


• Recognize opportunities for documentation improvement.


• Formulate clinically, compliant credible queries.


• Ability to successfully comply to robust auditing and CDI program monitoring


• Ability to apply coding conventions, official guidelines, and Coding Clinic advice to health record documentation.

Conifer requires its candidates, as applicable and as permitted by law, to obtain and provide confirmation of all required vaccinations and screenings prior to the start of employment. This may include, but is not limited to, the COVID-19 vaccination, influenza vaccination, and/or any future required vaccines and screenings.

Education / Experience

• Preferred: Acute Care nursing and/or Provider relevant experience


• Zero (0) to two (2) years CDI experience


• Two (2) plus years’ nursing experience – Medical/Surgical/Intensive Care and/or Case/Utilization Review


• Two (2) plus years’ Provider experience – Medical/Surgical/Intensive Care and/or Case/Utilization Review


• Graduate from a Nursing program, BSN, or graduate program; OR


• Graduate from Medical Doctor and/or Foreign Medical Doctor Program

CERTIFICATES, LICENSES, REGISTRATIONS

• Active state Registered Nurse license; OR


• Graduate MD and/or FMD license


• Preferred: CDIP or CCDS

PHYSICAL DEMANDS

• Ability to sit for extended periods of time.


• Ability to stand for extended periods of time.


• Must be able to efficiently use computer keyboard and mouse.


• Good visual acuity

WORK ENVIRONMENT

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Other

• Must be able to travel as needed, not to exceed 10%.

As a part of the Tenet and Catholic Health Initiatives family, Conifer Health brings 30 years of healthcare industry expertise to clients in more than 135 local regions nationwide. We help our clients strengthen their financial and clinical performance, serve their communities, and succeed at the business of healthcare. Conifer Health helps organizations transition from volume to value-based care, enhance the consumer and patient healthcare experience and improve quality, cost, and access to healthcare. Are you ready to be part of our solutions? Welcome to the company that gives you the resources and incentives to redefine healthcare services, with a competitive benefits package and leadership to take your career to the next step!

Employment practices will not be influenced or affected by an applicant’s or employee’s race, color, religion, sex (including pregnancy), national origin, age, disability, genetic information, sexual orientation, gender identity or expression, veteran status or any other legally protected status. Tenet will make reasonable accommodations for qualified individuals with disabilities unless doing so would result in an undue hardship.

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