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Clinical Documentation Integrity Registered Nurse, RN
Tenet HealthcareResponsible for reviewing medical records and ensuring quality physician documentation in a hybrid role based in Anniston, AL. Educating care team members on documentation guidelines and collaborating with providers for accurate coding.
About the role
Key responsibilities & impact- 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 quality of the physicians’ clinical documentation.
- Educates members of the patient care team regarding documentation guidelines, including the following: attending physicians, allied health practitioners, nursing, and case management.
- Completes initial medical records reviews of patient records within 24-48 hours of admission for a specified patient population to: (a) evaluate documentation to assign the principal diagnosis, pertinent secondary diagnoses, and procedures for accurate MS-DRG assignment, risk of mortality and severity of illness; and (b) record in business partner 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, as necessary.
- Formulate physician queries regarding missing, unclear, or conflicting health record documentation by requesting and obtaining additional documentation within the health record, as necessary.
- Collaborates with providers, case managers, nursing staff and other ancillary staff regarding documentation and to resolve physician queries prior to discharge.
Requirements
What you’ll need- Preferred: Acute Care nursing and/or Provider relevant experience
- Zero (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
- Ability to apply coding conventions, official guidelines, and Coding Clinic advice to health record documentation.
Benefits
Comp & perks- Conifer requires its candidates, as applicable and as permitted by law, to obtain and provide confirmation of all required vaccinations and screenings prior to the start of employment. This may include, but is not limited to, the COVID-19 vaccination, influenza vaccination, and/or any future required vaccines and screenings.
ATS Keywords
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Hard Skills & Tools
CDI experiencemedical record reviewdocumentation guidelinesMS-DRG assignmentacute care nursingcase managementutilization reviewcoding conventionshealth record documentation
Soft Skills
collaborationcommunicationeducationproblem-solving
Certifications
BSNMedical DoctorForeign Medical Doctor