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Clinical Documentation Improvement Specialist - RN
Job Overview
Day-to-day our Clinical Documentation Improvement Specialists are primarily responsible for evaluating concurrent documentation so that the medical record appropriately reflects the severity and risk of the patient’s conditions. Under the supervision of the CDI Leadership, CDI Specialists will conduct review of medical records to identify missing, vague and or incomplete diagnosis; communicate the need for additional documentation to the appropriate medial and clinical staff; ensure the additional documentation is completed in a timely manner; work collaboratively with other departments including Coding, Quality, Compliance, Medical Staff, Utilization Review/Case Management, Medical Records and any other applicable departments to improve the quality of physician documentation. This roles supports initiatives to improve the quality of documentation by all caregivers.
Required: Certifications/Licenses/Experience
- Active Registered Nurse (RN) in Indiana, Illinois and Kentucky or a compact licensed state
- Minimum of five (5) years of related adult, acute clinical experience required
Preferred: Certifications/Licenses/Experience
- Bachelor's Degree in Nursing (BSN)
- ACDIS certification preferred
Active RN license in Indiana, Illinois, Kentucky or compact state; 5+ years adult acute clinical experience; BSN and ACDIS certification preferred.
Key Responsibilities
- evaluating medical records
- identifying incomplete diagnoses
- collaborating with departments
Job Details
- Category: Healthcare Services - Nursing
- Seniority: Senior Level
- Commitment: Full Time
- Workplace: Remote — Evansville, Indiana, United States
- Salary: USD 59,716 – 83,595 / year
- Languages: English
About Deaconess Health System
A healthcare system providing clinical documentation improvement services. — Industry: Healthcare