RN CDI Specialist — Clinical Documentation Improvement

University of New Mexico - Hospitals; Edgewood (KY); Sur place; USD 65 000 - 90 000; Plein temps

Avantages offerts par ce poste

Sign-On Bonus Available

Relocation Assistance Available

Résumé du poste

University of New Mexico - Hospitals seeks a Clinical Documentation Improvement professional to review and optimize inpatient documentation. You will work with physicians and care teams to ensure documentation accurately reflects illness severity and service utilization.

Responsibilities include concurrent reviews, query communications, and CDI program reporting. Requires RN licensure in NM or reciprocal agreement and relevant CDI experience.

Qualifications

• Related Education and Experience may be substituted for one another on a year for year basis.

Responsabilités

• REVIEW – identify and record principal and secondary diagnoses, procedures, and assign a working MS-DRG.
• CONCURRENT REVIEW – perform initial concurrent review and re-reviews for admissions and document findings.
• PROBLEM SOLVING – interpret clinical info to suggest accurate documentation of illness severity.
• ABSTRACTS – monitor and report documentation quality and participate in meetings.
• COMMUNICATION – obtain/clarify diagnoses with physicians; promote effective queries.
• COORDINATION – facilitate communication among HIM, Utilization Review, and physicians.
• PROCESS IMPROVEMENT – develop and track improvement plans and outcomes.
• REPORTS – assist in distributing physician profiling reports for CDI program.
• REPORT ANALYSIS – assess documentation against severity of illness and outcomes.
• EDUCATION – educate physicians and staff on documentation and coding best practices.
• CONFIDENTIALITY – maintain HIPAA-compliant handling of records.

Formation

Program Graduate

Bachelor's Degree

Nationally Accredited Nursing Graduate

Nursing

Description du poste

University of New Mexico - Hospitals seeks a Clinical Documentation Improvement professional to review and optimize inpatient documentation. You will work with physicians and care teams to ensure documentation accurately reflects illness severity and service utilization.

Responsibilities include concurrent reviews, query communications, and CDI program reporting. Requires RN licensure in NM or reciprocal agreement and relevant CDI experience.