RN CDI Specialist: Elevate Medical Records

Nuvance Health; Norwalk (CT); On-site; USD 63,000 - 117,000; Full time

Job summary

Northwell Health is seeking a Clinical Documentation Improvement RN at Nuvance Health in CT/NY. You will drive documentation accuracy by collaborating with physicians, nursing staff and the coding team to reflect illness severity and resource use.

You will educate care teams on guidelines and maintain ongoing performance through 3M data, ensuring timely queries and high physician engagement while upholding hospital values and patient care standards.

Qualifications

• RN with 5 years recent experience in medical/surgical, critical care, ICU or ER preferred.
• BS or above preferred.
• Current NY/CT RN Licensure required.

Responsibilities

• Facilitates appropriate clinical documentation to ensure level of services and acuity are reflected in the medical record.
• Uses 3M and AHIMA guidelines; communicates with physicians to clarify documentation opportunities.
• Updates 3M with status changes, procedures, and lab results; ensures accurate principal diagnosis and comorbidities.
• Collaborates with coding staff to determine DRG and documentation needs; reconciles final DRG.
• Maintains ongoing education on the clinical documentation integrity program; mentors new staff.
• Maintains professional relationships with physicians and care teams; models Northwell Health values.
• Demonstrates regular attendance and the ability to prioritize multiple tasks.

Skills

Interpersonal communication

Analytical abilities

Independent work

Collaboration

Computer literacy

Education

RN licensure (CT/NY)

BS or higher preferred

Tools

Computer literacy

Job description

Northwell Health is seeking a Clinical Documentation Improvement RN at Nuvance Health in CT/NY. You will drive documentation accuracy by collaborating with physicians, nursing staff and the coding team to reflect illness severity and resource use.

You will educate care teams on guidelines and maintain ongoing performance through 3M data, ensuring timely queries and high physician engagement while upholding hospital values and patient care standards.