RN CDI Specialist – Clinical Documentation Improvement

University Of New Mexico - Hospitals; New Mexico; Sur place; USD 65 000 - 90 000; Plein temps

Avantages offerts par ce poste

Sign-On Bonus Available

Relocation Assistance Available

Résumé du poste

UNMH Jobs is seeking a Documentation Improvement Specialist (RN) to review and enhance clinical documentation during patient stays. You will collaborate with physicians and staff to ensure documentation accurately reflects illness severity and resource use, using CDI tools and MS-DRG assignments.

The role emphasizes education of clinicians, communication with care teams, and ongoing process improvement to support accurate coding and reporting, while adhering to HIPAA and hospital policies.

Qualifications

• 1 year directly related experience.
• Documentation improvement experience.

Responsabilités

• REVIEW - identify and record principal diagnoses and procedures, assign a working MS-DRG.
• CONCURRENT REVIEW - initiate tracking, document findings, and identify quality indicators.
• PROBLEM SOLVING - interpret clinical information and obtain documentation reflecting severity of illness.
• ABSTRACTS - track progress and report findings to HIM, QA, and Utilization Review/Case Management.
• COMMUNICATION - obtain/clarify diagnoses or comorbidities with physicians; educate as needed.
• COORDINATION - coordinate with HIM, Utilization Review, Quality Management, and physician leadership.
• PROCESS IMPROVEMENT - develop and implement process improvements; monitor outcomes.
• REPORTS - assist in communicating profiling reports from the CDI software.
• REPORT ANALYSIS - review documentation against severity of illness and outcomes.
• EDUCATION - provide guidance to physicians and staff on queries and documentation.
• CONFIDENTIALITY - maintain patient privacy per HIPAA.
• OTHER - perform other duties as assigned.
• COMPLIANCE - clarify documentation via queries to capture accurate severity and risk.

Formation

Program Graduate

Bachelor's Degree

Nationally Accredited Nursing Graduate

Nursing

Description du poste

UNMH Jobs is seeking a Documentation Improvement Specialist (RN) to review and enhance clinical documentation during patient stays. You will collaborate with physicians and staff to ensure documentation accurately reflects illness severity and resource use, using CDI tools and MS-DRG assignments.

The role emphasizes education of clinicians, communication with care teams, and ongoing process improvement to support accurate coding and reporting, while adhering to HIPAA and hospital policies.