RN - Clinical Documentation Integrity Specialist

Carle; Champaign, Northern (IL, KY); Hybrid; USD 47,000 - 81,000; Full time

Job summary

Carle Health is seeking a Clinical Documentation Improvement (CDI) specialist to review inpatient charts and ensure accurate documentation supporting DRG assignments, severity of illness, and mortality indicators. The role collaborates with physicians, nurses, and HIM coders to capture principal and secondary diagnoses and procedures.

Required: 2 years CDI experience and 2 years bedside clinical experience; RHIA or RN license within 6 months; associate degrees in Nursing or Health Information

Qualifications

• 2 years CDI experience
• 2 years clinical bedside experience
• RHIA or RN license within 6 months (if licensed in another state)

Responsibilities

• Conducts initial concurrent review for all selected admissions
• Clarifies documentation with physicians, nurses, and staff
• Ensures chart reflects true clinical picture and supports DRG
• Documents findings in Carle CDI software
• Coordinates with physicians, nurses, and HIM coding staff to capture Diagnoses and Procedures
• Follows query process and escalates as needed
• Performs education related to CDI topics
• Reviews denials and prepares appeal letters
• Follows workflow in EPIC and CDI software
• May participate in testing for upgrades

Skills

CDI

Nursing bedside experience

Education

Associate's Degree Nursing

Associate's Degree Health Information Mgmt

Doctorate degree Medicine

Tools

RHIA

Job description

Overview

Performs inpatient chart review to determine appropriate DRG assignment and assures appropriate documentation in the chart to support clinical care provided, including severity of illness and risk of mortality which impacts Case Mix Index and mortality ratings. Coordinates with physicians, nurses, ancillary staff, and the coders in Health Information Management to identify and record principal and secondary diagnoses, principal procedures, and assign the working DRG. Performs second level review of specific DRGs as assigned. Presents education related to CDI topics to peers and providers we needed or requested. Reviews DRG denials and provides information to the denials team related to appealing the encounter

Qualifications

**Must have 2 years of working Clinical Documentation experience and 2 years of Nursing or MD experience.**

Certifications: Registered Health Information Administrator (RHIA) - American Health Information Management Association (AHIMA); or Licensed Registered Professional Nurse (RN) within 6 months - if licensed in another state - Illinois Department of Financial and Professional Regulation (IDFPR),

Education: Associate's Degree Nursing; or Associate's Degree Health Information Mgmt, or Doctorate degree Medicine

Work Experience: 2yrs CDI; 2yrs Clinical bedside

Responsibilities

• Conducts the initial concurrent review process for all selected admissions.
• Clarifies documentation in the medical record as appropriate through communication with the physicians, nurses, and ancillary staff.
• Assures documentation in chart represents a true clinical picture of the patient diagnoses and supports care that was given and DRG assigned.
• Documents findings within Carle CDI software and updates software as required to reflect status of the encounter and any follow up.
• Coordinates with the physicians, nurses, ancillary hospital staff, and Health Information Management Department's coding staff to identify and record principal and secondary diagnoses, principal procedures, and assign the working DRG.
• Follows query process and escalates as necessary.
• Conducts education related to CDI topics to peers and providers as needed or requested.
• Performs second level review on selected inpatient encounters.
• Reviews denials for accurate and complete documentation and develops appeal letter when needed.
• Attends mandatory and regular education sessions as needed.li>
• Follows appropriate workflow in EPIC and CDI software and notifies one up leader of any issues.
• May serve as an "expert" and participate in testing for upgrades as needed.

About Us

Find it here.

Discover the job, the career, the purpose you were meant for. At Carle Health, we're committed to fostering a workplace where every team member feels valued, respected and empowered, where passion and purpose come together to positively impact the lives of our patients and our communities. Find it all at Carle Health.

Our nearly 17,000 team members and providers work together to support patient care across central and southeastern Illinois. We’ve grown to include eight, award-winning hospitals and a multispecialty provider group with more than 1,500 doctors and advanced practice providers. We’re developing the next generation of providers and healthcare professionals through Carle Illinois College of Medicine, the world’s first engineering-based medical school, and Methodist College. Carle BroMenn Medical Center, Carle Foundation Hospital, Carle Health Methodist Hospital, Carle Health Proctor Hospital, Carle Health Pekin Hospital, and Carle Hoopeston Regional Health Center hold Magnet® designations, the nation’s highest honor for nursing care. We offer opportunities in several communities throughout central Illinois with potential for growth and life-long careers at Carle Health.

We are an Equal Opportunity Employer and do not discriminate against any employee or applicant for employment because of race, color, sex, age, national origin, religion, sexual orientation, gender identity, status as a veteran, and basis of disability or any other federal, state or local protected class. Carle Health participates in E-Verify and may provide the Social Security Administration and, if necessary, the Department of Homeland Security with information from each new employee's Form I-9 to confirm work authorization. | For more information: [e-mail].

Compensation and Benefits

The compensation range for this position is $34.31per hour - $59.01per hour. This represents a good faith minimum and maximum range for the role at the time of posting by Carle Health. The actual compensation offered a candidate will be dependent on a variety of factors including, but not limited to, the candidate’s experience, qualifications, location, training, licenses, shifts worked and compensation model.Carle Health offers a comprehensive benefits package for team members and providers. To learn more visit careers.carlehealth.org/benefits.