Clinical Documentation Specialist; Registered Nurse

Job Summary

• The CDI Specialist performs clinically based initial, concurrent, and retrospective review of inpatient medical records to evaluate documentation as it correlates to the utilization of acute care services.
• The CDI Specialist employs critical thinking skills to discern Physician documentation of care to accurately reflect patient severity of illness and risk of mortality
• Assumes the responsibility and accountability for improving the overall quality and completeness of clinical documentation to aid in compliant reimbursement for acute care services and in reporting quality of care outcomes.
• Provides ongoing training to physicians and serve as a subject matter expert for clinical documentation standards.

Bachelor of Science in Nursing required (or equivalent experience in Clinical Documentation Excellence considered).

• Current Alabama Registered Nurse license or valid eNLC multistate RN license required.
• At least one of the following certifications:
  • Certified Clinical Documentation Specialist by the Association of Clinical Documentation Integrity Specialists
  • Clinical Documentation Improvement Professional by the American Health Information Management Association
  • Certified Professional Coder by the American Academy of Professional Coders
  • Certified Coding Specialist

• Minimum five (5) years of acute care hospital nursing experience.
• Two (2) years of Clinical Documentation Excellence experience in an acute care setting.

Analytical skills; strong computer skills; ability to multi-task; detail oriented; good written; oral and interpersonal communication skills; working knowledge of medical terminology and pharmacology.