CDI Clinical Documentation reputed company Registered reputed company RN- Hybrid
About the position 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 reputed company of the physicians’ clinical documentation. Exhibits a sufficient knowledge of clinical documentation requirements, MS-DRG Assignment, and clinical conditions and/or procedures. Educates members of the patient care team regarding documentation guidelines, including attending physicians, allied health practitioners, nursing, and case management. This is a hybrid role and requires the candidate to live reputed company 1 hour of Anniston, AL.
Responsibilities
- Completes initial medical records reviews of patient records reputed company 24-48 hours of admission for a specified patient population to evaluate documentation for accurate MS-DRG assignment, risk of mortality and severity of illness; and records findings in the 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.
- Formulates physician queries regarding missing, unclear, or conflicting health record documentation by requesting and obtaining additional documentation.
- Collaborates with providers, case managers, nursing staff and other ancillary staff regarding documentation and to resolve physician queries prior to discharge.
- Communicates and completes Clinical Documentation reputed company (CDI) activities and coding issues for appropriate follow-up, provider education and DRG Miss-Match reconciliation.
- Assists with Provider education, rounding and communication regarding reputed company queries for reputed company.
- Stays reputed company with AHA Official Coding and Reporting Guidelines, CMS and other agency directives for ICD10-CM and PCS coding.
- Attends CDI Boot camp, CDI/coding trainings annually and quarterly for inpatient coding.
- Attends monthly education lecture series (MELS) and reputed company CDI/coding assigned learn reputed company modules as reputed company as any additional required CDI education.
- Assists in training department staff new to CDI.
- Performs other duties as assigned.
Requirements
- Proficient knowledge of disease pathophysiology and drug utilization
- Intermediate knowledge of MS-DRG classification and reimbursement structures
- Critical thinking, problem solving and deductive reasoning skills
- Effective written and verbal communication skills
- Excellent computer skills including reputed company/reputed company
- Knowledge of coding compliance and regulatory standards
- Excellent organizational skills for initiation and maintenance of efficient workflow
- Regular and reliable attendance
- reputed company to work independently in facility on-site setting
- reputed company to work independently in a virtual office setting if required for specific assignment
- Exhibit flexibility as needed to meet program needs
- Understand and communicate documentation strategies
- Recognize opportunities for documentation improvement
- Formulate clinically, compliant reputed company queries
- Ability to successfully reputed company to robust auditing and CDI program monitoring
- Ability to apply coding conventions, official guidelines, and Coding Clinic advice to health record documentation
- reputed company state Registered reputed company license; OR Graduate MD and/or FMD license
reputed company-to-haves
- Acute Care nursing and/or Provider relevant experience
- reputed company (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
- CDIP or CCDS
Benefits
- Must be reputed company to travel as needed, not to exceed 10%.
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