Registered Nurse Clinical Documentation Integrity Specialist - Inpatient

Provides concurrent review of the clinical documentation in the medical record; review the medical record with a clinical lens to identify any missing or understated diagnoses. Queries the medical staff when necessary, by written and/or verbal communication to obtain accurate and complete physician documentation that supports the patient condition(s) and treatment plan. Performs a thorough chart review to determine the appropriate principal diagnosis of the patient. Coordinates with coding/HIM/UR and other departments to achieve a record that reflects the acuity of the patient and level of care provided.

Responsibilities

Provides concurrent review of clinical documentation in the medical record; Identifies missing or understated diagnoses; Queries medical staff to obtain accurate and complete physician documentation; Performs thorough chart review to determine appropriate principal diagnosis; Coordinates with coding/HIM/UR and other departments; Documents findings in workflow tools; Provides education to physicians on documentation; Adheres to TMC values and policies

Requirements

Graduation from a qualified, nationally-accredited nursing program; Three (3) years of RN clinical experience in an acute care setting; Current RN licensure permitting work in state of Arizona; Extensive clinical knowledge and understanding of pathology/physiology; Strong critical thinking skills and the ability to review the medical record to identify information not yet documented but supported by clinical indicators or clinical clues; Knowledge of age-specific patient needs and the elements of disease processes and related procedures; Excellent written and verbal communication skills; Assertive personality traits to facilitate ongoing physician communication; Working knowledge of inpatient admission criteria; Ability to work independently in a time-oriented environment; Ability to stand and walk in the performance of job responsibilities; Knowledge of the importance of capturing all appropriate secondary diagnoses for quality rating purposes

Nice to have

CDI experience preferred; CCDS (Certified Clinical Documentation Specialist) from ACDIS or CDIP (Certified Documentation Improvement Practitioner) from AHIMA preferred