RN – Clinical Documentation Integrity Specialist

Jobtailor; Madison (WI); On-site; USD 85,000 - 120,000; Full time

Job summary

Jobtailor seeks a Clinical Documentation Integrity professional to act as a liaison between clinicians and coders, ensuring documentation supports patient care and quality outcomes.

Under the Clinical Documentation Integrity Supervisor, you will conduct concurrent reviews of inpatient records, seek clarification before discharge, and impact reimbursement through accurate documentation and documentation clarification.

Qualifications

• Associate's Degree in Registered Nursing is required.
• 3 years nursing, case management, utilization review or quality resources in acute care required.
• WI RN license or other NLC jurisdiction required on hire.
• Certified Clinical Documentation Specialist or CDI Practitioner preferred.

Responsibilities

• Function as a liaison between clinicians and coders.
• Provide expert information on how documentation affects patient care, quality outcomes, and reimbursement.
• Under supervision, perform concurrent reviews of inpatient records to seek clarification before discharge.

Skills

Clinical Documentation Integrity

Communication

Collaboration

Liaison Skills

RN License

Education

Associate's Degree in Registered Nursing

BSN Preferred

Tools

Clinical Documentation Review

Quality Outcomes Measures

Utilization Review

Reimbursement Impact Analysis

Job description

• Function as a liaison between clinicians and coders
• Work as an expert source for information regarding the impact of documentation on patient care, quality outcomes measures, risk of mortality/severity of illness indicators, and accurate reimbursement
• Work under the direction of the Clinical Documentation Integrity Supervisor, conduct concurrent review of inpatient medical records-seeking clarification of documentation before the patient is discharged

Requirements

• Associate's Degree in Registered Nursing Required
• Bachelor's Degree of Science in Nursing (BSN) Preferred
• 3 years nursing, case management, utilization review or quality resources experience in an acute care setting Required
• 3 years Clinical Documentation Integrity experience highly desirable Preferred
• 5 years nursing, case management, utilization review, or quality resources experience in an acute care setting Preferred
• Licensed as a Registered Nurse (RN) in the State of WI or holds a license issued by a jurisdiction that has adopted the nurse licensure compact Upon Hire Required
• Certified Clinical Documentation Specialist Preferred or
• Certified Documentation Improvement Practitioner Preferred

Core Competencies

Demonstrates expertise in Clinical Documentation Integrity, ensuring accurate documentation impacts patient care and quality outcomes. Proficient in conducting concurrent reviews of medical records and liaising between clinicians and coders.

Highest-signal resume keywords

• Clinical Documentation Integrity
• Registered Nurse (RN) License
• Nursing Experience in Acute Care
• Certified Clinical Documentation Specialist
• Utilization Review

ATS Optimization Keywords

Hard Skills

• Clinical Documentation Review
• Patient Care Quality Outcomes
• Risk of Mortality Indicators
• Severity of Illness Indicators
• Documentation Impact Analysis

Soft Skills

• Communication
• Collaboration
• Liaison Skills

Certifications & Qualifications

• Certified Clinical Documentation Specialist
• Certified Documentation Improvement Practitioner

Industry Keywords

• Acute Care Setting
• Case Management
• Utilization Review
• Quality Resources
• Documentation Clarification