Clinical Documentation Integrity Registered Nurse,RN Job Anniston area,Alabama USA,Nursing

Responsible for reviewing medical records to facilitate and obtain appropriate physician documentation for any clinical conditions or procedures to support the appropriate severity of illness, expected risk of mortality, and complexity of care of the patient, by improving the quality of the physicians’ clinical documentation.
Educates members of the patient care team regarding documentation guidelines, including the following: attending physicians, allied health practitioners, nursing, and case management.
Completes initial medical records reviews of patient records within 24-48 hours of admission for a specified patient population to: (a) evaluate documentation to assign the principal diagnosis, pertinent secondary diagnoses, and procedures for accurate MS-DRG assignment, risk of mortality and severity of illness; and (b) record in business partner designated CDI tool and/or host medical record system.
Conducts follow‑up reviews of patients every 24‑48 hours or as needed up through discharge to support assigned working MS‑DRG assignment upon patient discharge, as necessary.
Formulates physician queries regarding missing, unclear, or conflicting health record documentation by requesting and obtaining additional documentation within the health record, as necessary.
Collaborates with providers, case managers, nursing staff and other ancillary staff regarding documentation and to resolve physician queries prior to discharge.

Requirements

Preferred:
Acute Care nursing and/or Provider relevant experience
Zero (0) to two (2) years CDI experience
Two (2) plus years’ nursing experience – Medical/Surgical/Intensive Care and/or Case/Utilization Review
Two (2) plus years’ Provider experience – Medical/Surgical/Intensive Care and/or Case/Utilization Review
Graduate from a Nursing program, BSN, or graduate program; OR
Graduate from Medical Doctor and/or Foreign Medical Doctor Program
Ability to apply coding conventions, official guidelines, and Coding Clinic advice to health record documentation.

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Clinical Documentation Integrity Registered Nurse, RN