Clinical Documentation Specialist – CDI

Responsibilities

• Assists with the appropriate identification of diagnoses, conditions, and/or procedures that are representative of the patient’s hospital stay and care provided
• Initiates concurrent queries to providers as supported by medical record documentation to improve the accuracy, integrity, and quality of patient data
• Reviews inpatient records to ensure completeness, accuracy, and clinical validation
• Evaluates documentation for assignment of working and possible DRG
• Recognizes opportunities for documentation improvement
• Identifies opportunities to query physicians regarding missing, unclear, or conflicting documentation
• Interacts directly with physicians to request and obtain additional documentation when needed
• Facilitates modifications to physician documentation to reflect the complexity of care of the patient
• Collaborates with and educates members of the patient care team regarding documentation guidelines

• Bachelor’s in Nursing, required
• RN License
• 1-2 years of medical/surgical nursing experience in the acute hospital setting
• Critical Care and/or Emergency Nursing experience required
• Proficient skill in query writing to physicians
• Knowledge to accurately complete chart audits
• Organizational and critical thinking skills required
• Experience with computer systems required, including web-based applications and some Microsoft Office applications which may include Outlook, Word, Excel, PowerPoint, or Access