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Clinical Documentation Integrity Registered Nurse, RN
Tenet HealthcareClinical Documentation Integrity Registered Nurse reviewing medical records to improve quality of physician documentation. Educating care team on documentation guidelines with a focus on compliance and accuracy.
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
- Completes initial medical records reviews of patient records within 24-48 hours of admission
- Conducts follow-up reviews of patients every 24-48 hours or as needed
- Formulate physician queries regarding missing, unclear, or conflicting health record documentation
- Collaborates with providers, case managers, nursing staff and other ancillary staff regarding documentation
- Communicates/Completes Clinical Documentation Integrity (CDI) activities and coding issues
- Assists with Provider education, rounding and communication regarding open queries for resolution
- Stays current with AHA Official Coding and Reporting Guidelines
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
- Active state Registered Nurse license; OR
- Graduate MD and/or FMD license
- Preferred: CDIP or CCDS
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
Medical Records ReviewClinical Documentation Integrity (CDI)Formulating Physician QueriesDocumentation Guidelines EducationCoding Issues Communication
Soft Skills
CollaborationCommunication
Certifications
CDIPCCDS