Clinical Documentation Improvement (CDI) Specialist - requires RN - Full Time
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US
Company:
Virtua Health is a Magnet-recognized health system dedicated to providing exceptional care in South Jersey with over 14,000 colleagues.
Summary:
The CDI Specialist evaluates and analyzes medical records to ensure proper documentation and collaborate with healthcare personnel. Candidates must have clinical experience, RN licensure, and proficiency in office software.
Requirements:
Technology: Microsoft Excel, Microsoft Word, Microsoft Access, Microsoft Power Point
Hard Skills: Analytical skills, Coding skills with experience in ICD-9-CM
Credentials: Bachelor’s degree
Experience: Two years hospital clinical experience required
Job Description:
Clinical Documentation Improvement (CDI) Specialist - requires RN - Full Time
Location: 100% Remote
Employment Type: Employee
Employment Classification: Regular
Time Type: Full time
Work Shift: 1st Shift (United States of America)
Total Weekly Hours: 40
Job Information:
Summary:
Evaluates and analyzes medical records concurrently for proper documentation. Collaborates with HIM Coders, clinicians, and medical staff to ensure timely and accurate documentation that supports the diagnosis and treatment of the patient.
Position Responsibilities:
• Evaluates and analyzes medical records concurrently for proper documentation. This review includes new admissions to the facility, as well as re-reviews every two – three days until the patient is discharged.
• Manages and trends data collection for an assigned hospital / facility/ specialty.
• The CDI Specialist is the primary source to verify diagnoses in the medical record for proper DRG coding. When symptoms in the medical record require further documentation, the CDI Specialist queries the physician for a specific diagnosis/procedure for more accurate DRG coding.
• Collaborates with HIM Coders, clinicians, and physicians to ensure documentation that supports the diagnosis and treatment of the patient is timely and accurate documentation.
• Provides on-going training and education to the clinicians and physicians during 1:1, physician group, performance improvement, and ad hoc meetings.
• Collaborates with Quality and Case Management Department by reviewing medical records that are not meeting standards, and assists with the development of action plans to improve documentation for peer review of medical and nursing staff’s documentation.
• Assists the Director and the hospital team in with preparation, coordination, and response to areas of documentation improvement.
• When fall outs of accepted criteria occur, the CDI Specialists reviews the information with the physicians, clinicians, HIM, and Quality Department.
• Assists with the development and implementation of performance improvement activities according to the Virtua Quality Plan.
• Uses the DMAIC cycle and assists in educating and coaching staff, managers, and physicians in its use.
Position Qualifications Required / Experience Required:
Two years hospital clinical experience required.
Must demonstrate the ability to accurately use a computer and standard office software such as Microsoft Excel, Word, Access, and Power Point.
Analytical skills.
Must demonstrate effective verbal and written communication skills.
Must be able to establish and maintain an effective rapport with staff, physicians, managers, and administrators.
Ability to coordinate multiple tasks and flexibility to balance changing priorities.
Coding skills with experience in ICD-9-CM and working knowledge of the AHA Coding Clinic preferred.
Current RN Licensure required.
Annual Salary: $77,405 - $123,574
The actual salary/rate will vary based on applicant’s experience as well as internal equity and alignment with market data.