RN CDI Specialist: Clinical Documentation Improvement

University Of New Mexico - Hospitals; Corrales (NM); Sur place; USD 70 000 - 90 000; Plein temps

Avantages offerts par ce poste

Sign-On Bonus Available

Relocation Assistance Available

Résumé du poste

UNMH is seeking a Clinical Documentation Improvement Specialist to review inpatient records during hospitalization to ensure accurate diagnoses and procedures, supporting MS-DRG assignments and severity of illness.

You will collaborate with physicians and care teams, provide ongoing training on documentation, and contribute to program reporting while upholding HIPAA and hospital policies. This is a full‑time, on‑site position in the HIM Clinical Documentation department.

Qualifications

• 1 year of directly related experience
• RN license in NM or as allowed by reciprocal agreement
• Certified Coding Specialist (CDS) or related credential (optional)
• Certified Doc Improvement Prac/Spec (CDIP or CDIS) optional

Responsabilités

• REVIEW - Identify and record principal/secondary diagnoses and procedures, assign a working MS-DRG.
• CONCURRENT REVIEW - Conduct initial and ongoing reviews, document findings on MS-DRG worksheets.
• PROBLEM SOLVING - Interpret clinical data, evaluate meds/vitals, identify potential diagnoses and obtain documentation.
• ABSTRACTS - Track Documentation Improvement Program progress and report findings to HIM, QMD, UR/CM.
• COMMUNICATION - Obtain/clarify diagnoses with physicians; address resistance to documentation improvement.
• COORDINATION - Facilitate communication among HIM, UR/CM, Quality Management, and physician leadership.
• PROCESS IMPROVEMENT - Create and implement process improvement plans; monitor outcomes.
• REPORTS - Assist in distributing physician profiling reports and related metrics.
• REPORT ANALYSIS - Review documentation for severity of illness and report to stakeholders.
• EDUCATION - Educate providers and staff on queries and documentation impact.
• CONFIDENTIALITY - Maintain HIPAA-compliant confidentiality.
• OTHER - Perform additional duties as assigned.
• COMPLIANCE - Clarify documentation using query tools to reflect patient illness severity.

Formation

Program Graduate

Bachelor's Degree

Nationally Accredited Nursing Graduate

Nursing

Description du poste

UNMH is seeking a Clinical Documentation Improvement Specialist to review inpatient records during hospitalization to ensure accurate diagnoses and procedures, supporting MS-DRG assignments and severity of illness.

You will collaborate with physicians and care teams, provide ongoing training on documentation, and contribute to program reporting while upholding HIPAA and hospital policies. This is a full‑time, on‑site position in the HIM Clinical Documentation department.