RN Clinical Documentation Improvement Specialist - Clinical Doc Mgmt Program - FT

IntelliResume; Sayre (Bradford County); On-site; USD 70,000 - 90,000; Full time

Job summary

IntelliResume is seeking an RN Clinical Documentation Improvement Specialist to enhance the quality and completeness of clinical documentation. You will work with physicians, nurses, and coding staff to ensure documentation accurately reflects services and supports quality outcomes.

Required: RN license, BSN, and specialty certification within 3 years of hire; five years of acute hospital experience; strong communication, assessment and analytical skills; CDI experience preferred.

Qualifications

• RN license and BSN required.
• Certification in area of specialty within 3 years of hire.
• Five years of acute clinical experience in a hospital setting required.
• Excellent communication, assessment/observation, analytical thinking and problem solving skills.
• Prior CDI experience preferred.

Responsibilities

• Facilitates modifications to clinical documentation to reflect services rendered for proper coding, billing and reimbursement.
• Reviews admission and continued stay documents using CDMP guidelines.
• Collaborates with hospital quality, case management and coding staff to improve documentation quality.
• Educates internal customers on compliant documentation opportunities, coding and reimbursement issues.
• Maintains ongoing continuing education (minimum 8 hours per year).

Skills

Excellent communication

Analytical thinking

Problem solving

Assessment/observation skills

Team collaboration

Education

RN License

BSN

Certification in specialty area

Tools

CDMP software

CDMPTrak

CDMP reporting tools

Job description

RN Clinical Documentation Improvement Specialist - Clinical Doc Mgmt Program - FT

Shift: Day

Position Summary

Responsible for improving the overall quality and completeness of clinical documentation Facilitates modifications to clinical documentation through interaction with physicians, nursing staff, other patient caregivers, medical records coding staff to ensure that clinical documentation accurately reflects service rendered to patient. Supports the accuracy and completeness of clinical information used for measuring and reporting physician and medical center outcomes. Provides education to members of the health care team on an ongoing basis using diverse methodology.

Education, License & Cert

• RN License Required
• BSN Required
• Certification in area of specialty required within 3 years of hire

Experience

Prior CDI experience preferred. Five years recent acute clinical experience in a hospital setting required. Critical care, utilization review or coding experience required. Requires excellent communication skills (both verbal and written), assessment/observation skills, demonstrated analytical thinking, and problem solving skills. Meets minimum score on pre‑hire competency test.

Essential Functions

1. Facilitates modifications to clinical documentation for designated patients to ensure that documentation reflects the level of services rendered which supports proper coding, billing and reimbursement and quality of care outcomes.
   • Completes admission and continued stay reviews using the CDMP guidelines
   • Reviews concurrent documentation from all disciplines to capture best practice quality indicators
   • Conducts follow‑up reviews of clinical documentation to ensure points of clarification have been recorded in the patient’s chart.
   • Completes reviews in a timely manner as outlined in CDMP guidelines.
2. Demonstrates knowledge of CDMP guidelines and program, DRG payor issues, documentation opportunities, clinical documentation requirements, and referral policies and procedures.
   • Collaborates with hospital quality team, case managers and coding specialists.
   • Clarifies questions with other coder specialists and/or department manager.
   • Educates internal customers on compliant documentation opportunities, coding and reimbursement issues, as well as performance improvement methodologies.
   • Reviews clinical issues with coding staff to assign a working DRG.
3. Utilizes CDMP software/computer applications.
   • Updates worksheets to reflect any changes in status, procedures/treatments, and conferring with physicians to finalize diagnoses and quality measures.
   • Assists with management of CDMPTrak and reporting as designated.
   • Assists with special projects as requested.
4. Facilitates teamwork and performance improvements in the organization.
   • Communicates in a positive and productive manner.
   • Promotes growth and education of others by sharing knowledge and resources.
   • Works collaboratively with other department staff and physicians.
   • Participates in performance improvement activities.
   • Maintains minimum 8 hrs continuing education per year

Other Duties

It is understood that this description is not intended to be all inclusive, and that other duties may be assigned as necessary in the performance of this position.