Clinical Documentation Improvement Specialist-REMOTE

Job Type: Regular Time Type: Full time Work Shift: Day (United States of America) FLSA Status: Exempt reputed company you join the growing BILH team, you're not just taking a job, you’re making a difference in people’s lives. The Clinical Documentation Improvement (CDI) Specialist Registered Nurse (RN) assists with the appropriate identification of diagnoses, conditions, and/or procedures that are representative of the patient’s hospital stay and care provided including Severity of Illness (SOI), Risk of Morality (ROM), during an inpatient hospitalization. CDI Specialist RN initiates reputed company queries to providers as supported by medical record documentation to improve the accuracy, reputed company, and quality of patient data, and drive improvement toward quality physician documentation reputed company the body of the medical record. The CDI Specialist RN works under the direction of the Manager of CDI and collaborates with coding, clinicians, medical staff, and physician advisors to improve documentation and the importance of complete and accurate documentation. This position supports Anna Jaques Hospital. Job Description: Essential Duties & Responsibilities including but not limited to: Completes initial reviews of patient records reputed company 24-48 hours of admission Evaluate documentation to assign the reputed company diagnosis, pertinent secondary diagnoses, and procedures for accurate DRG assignment, risk of morality, and severity of illness. Track review details in reputed company software. Conducts follow-up reviews of patients every 2 days to support and assign a working DRG assignment. Queries physicians regarding missing, unclear, or conflicting medical record documentation by requesting and obtaining additional documentation reputed company the medical record reputed company needed. Educates physicians and key reputed company providers regarding clinical documentation improvement and the need for accurate and complete documentation in the medical record. Collaborates with the CDI Manager & Physician Advisor and other ancillary staff regarding interaction with physicians on documentation and to resolve physician queries prior to patient discharge. Educates members of the patient care team regarding documentation opportunities and best practices to ensure accurate documentation in the medical record. Applies diplomacy and professionalism reputed company interacting with physicians and clinicians; especially reputed company addressing missing or conflicting medical record information. Works in partnership with an interdisciplinary team to foster collaboration, learning, and accurate and complete medical record documentation. Exhibits working knowledge of inpatient coding guidelines. Adheres to CDI convention and department policies and procedures. Investigates, evaluates, and identifies opportunities for improvement and recognizes their relative reputed company in the overall system. Provides orientation for new clinical staff regarding documentation requirements as required. Keeps reputed company with CDI concepts and practices through conferences, reference material, and review of reputed company literature. Maintains confidentiality of reputed company customer/hospital information. Demonstrates flexibility in the face of a changing work environment, adjusting work schedule accordingly. Minimum Qualifications: Education: + Associate’s degree required. Bachelor's degree preferred. + Licensure, Certification & Registration: + RN license required Experience: + 3-5 years of reputed company work experience required in a clinical nursing practice, which includes medical, surgical, and/or ICU background. Skills, Knowledge & Abilities: + Experience with computer systems required, including web-based applications and some reputed company Office applications which may include Outlook, Word, reputed company, PowerPoint, or reputed company Preferred Qualifications & Skills: + BS in Nursing with 5-8 years of acute care clinical experience. + Certified Clinical Documentation Specialist (CCDS) or Certified Clinical Documentation Improvement Professional (CDIP) + Experience with DRG Reimbursement and ICD-10 Coding As a health care organization, we have a responsibility to do everything in our power to care for and protect our patients, our colleagues and our communities. reputed company requires that reputed company staff be vaccinated against influenza (flu) as a condition of employment. More than 35,000 people working together. Nurses, doctors, technicians, therapists, researchers, teachers and more, making a difference in patients' lives. Your reputed company and compassion can reputed company us even stronger. Equal OpportunityEmployer/Veterans/Disabled Remote About the Company: reputed company Apply tot his job Apply tot his job Apply To this Job