RN CDI Specialist: Elevate Medical Record Quality

Datavant; Helena (MT); On-site; USD 55,000 - 62,000; Full time

Job summary

Datavant is seeking a Clinical Documentation Quality Improvement Specialist to elevate medical record documentation and DRG accuracy. You will review inpatient records, collaborate with physicians to clarify documentation, and drive compliant coding practices to improve healthcare data quality.

The role requires an RN license, BSN, and CCDS or CDIP certification, with at least 3 years in CDI and academic medical center settings.

Qualifications

• 3+ years of CDI experience.
• 3+ years of clinical experience in an academic medical center.
• Registered Nurse license, Bachelor's degree in Nursing.
• CCDS or CDIP certification required.
• Must pass a CDI skills competency assessment.

Responsibilities

• Conduct timely, accurate, and complete documentation reviews for selected inpatient records, addressing inadequate or conflicting documentation.
• Collaborate with physicians and caregivers to ensure appropriate reimbursement and clinical severity for DRG-based payer patients.
• Demonstrate understanding of complications, co-morbidities, severity of illness, risk of mortality, case mix index, secondary diagnoses, and procedure impact on DRG.
• Improve coding specificity by educating physicians and caregivers on the importance of clear documentation throughout a patient's stay.
• Follow AHA guidelines and coding clinics for accurate coding and required documentation to ensure compliance.
• Query physicians regarding missing, unclear, or conflicting health record documentation to obtain necessary details.
• Maintain daily production logs for evaluation, tracking cases reviewed, queries placed/responded, etc.
• Perform follow-up reviews to confirm recorded points of clarification in the patient's medical record.
• Ensure confidentiality of all files, documents, and records.
• Meet or exceed production and quality metrics.

Skills

CDI experience

Clinical nursing

Documentation improvement

Education

BSN

Job description

Datavant is seeking a Clinical Documentation Quality Improvement Specialist to elevate medical record documentation and DRG accuracy. You will review inpatient records, collaborate with physicians to clarify documentation, and drive compliant coding practices to improve healthcare data quality.

The role requires an RN license, BSN, and CCDS or CDIP certification, with at least 3 years in CDI and academic medical center settings.