RN CDI Specialist - Clinical Documentation Expert

Tenet Healthcare; Birmingham, Northern (AL, KY); Hybrid; USD 60,000 - 90,000; Full time

Job summary

Conifer Health is seeking a CDI Specialist to review medical records and ensure accurate documentation for proper MS-DRG assignment and severity of illness. You will educate care team members on documentation guidelines and collaborate with providers to resolve queries.

Responsibilities include initial and follow-up record reviews, formulating clinically credible queries, and staying current with CDI guidelines and in-house tools. Travel may be required to support facilities.

Qualifications

• Zero to two years CDI experience.
• Two plus years nursing experience – Medical/Surgical/ICU and/or Case/Utilization Review.
• Graduate from Nursing program, BSN, or graduate program; OR Graduate from Medical Doctor and/or Foreign Medical Doctor Program.

Responsibilities

• Record Review within 24-48 hours of admission to evaluate documentation for MS-DRG assignment and mortality risk.
• Conduct follow-up reviews every 24-48 hours through discharge to support MS-DRG on discharge.
• Formulate physician queries for missing/unclear documentation and obtain additional records.
• Collaborate with providers, case managers, nursing staff and other staff to resolve physician queries prior to discharge.

Skills

teamwork

time management

medical records review

MS-DRG knowledge

critical thinking

communication

MS Word/Excel

coding compliance

organization

independent work

flexibility

documentation strategies

CDI

Education

BSN (preferred)

Registered Nurse license

MD/Foreign MD background

Tools

CDI software tools

MS-DRG coding tools

Job description

Conifer Health is seeking a CDI Specialist to review medical records and ensure accurate documentation for proper MS-DRG assignment and severity of illness. You will educate care team members on documentation guidelines and collaborate with providers to resolve queries.

Responsibilities include initial and follow-up record reviews, formulating clinically credible queries, and staying current with CDI guidelines and in-house tools. Travel may be required to support facilities.