Clinical Documentation Specialist RN (1.0 FTE, Days)

Wage Range

$48.66 - $77.84 per hour

• Posted wage ranges represent the entire range from minimum to maximum.
• For jobs with more than one level, the posted range reflects the minimum of the lowest level and the maximum of the highest level.
• Some positions also offer additional premiums based on shift, certifications or degrees.
• Job offers are determined based on a candidate's years of relevant experience, level of education and internal equity.
• Job Summary: Working under department management the Clinical Documentation Specialist RN ensures the documentation in the patient health record accurately reflects the severity of illness, expected risk of mortality and the level of services provided to the patient.
• Utilizing defined review and query processes the CDI RN completes a comprehensive review of inpatient medical records and facilitates clinical documentation correction through collaborative interaction with providers, other patient care givers and with the Medical Center Coding Staff to ensure the encounter record is complete and accurate for reimbursement and outcome reporting.
• Primary Duties: 1.
• Reviews inpatient admissions to identify and improve clinical documentation in the medical record to reflect appropriate severity of illness, risk of mortality and quality of care provided.
• Uses a worksheet format to document reviews in order to facilitate reporting and process improvement activities.
• 2.
• Communicates with physicians and coders to ensure accurate and complete documentation in the medical record that reflects the clinical condition of the patient in language that can be coded appropriately.
• 3.
• Utilizes clinical knowledge and understanding of coding guidelines to analyze clinical information and assign a working DRG 4.
• Formulates compliant and credible clinical documentation queries to improve documentation 5.
• Conducts timely post discharge reviews for clinical validation, DRG mismatches or other documentation clarification need.
• 6.
• Performs other duties as assigned.

License, Certification, Education or Experience

• REQUIRED for the position: