Registered Nurse Clinical Documentation Integrity Specialist - Inpatient

Clinical Documentation Improvement Specialist

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.

Essential Functions:

• Conducts initial and follow-up concurrent reviews on inpatient admissions for opportunities to clarify documentation in the medical record for accurate reflection of the acuity of the patient and justifying the level of care.
• Uses relationship building and strong communication skills to develop a rapport with providers to clarify information in the medical record. Uses appropriate querying templates to get needed documentation. Conducts follow-up on unanswered queries during the patient stay to obtain a response to unanswered queries.
• Provides education to physicians on the importance of complete documentation and key documentation concepts during regular physician meetings or on individually with physicians.
• Use data provided by managers, directors, and consulting team to actions to identify what is working well and areas of focus.
• Adheres to and supports team members in exhibiting TMCH values of integrity, community, compassion, and dedication.
• Adheres to TMC organizational and department-specific safety, confidentiality, values, policies and standards.
• Performs related duties as assigned.

Minimum Qualifications:

Education: Graduation from a qualified, nationally-accredited nursing program.

Experience: Three (3) years of RN clinical experience in an acute care setting. CDI experience preferred.

Licensure or Certification: Current RN licensure permitting work in state of Arizona. CCDS (Certified Clinical Documentation Specialist) from ACDIS or CDIP (Certified Documentation Improvement Practitioner) from AHIMA preferred.

Knowledge, Skills and Abilities:

• Extensive clinical knowledge and understanding of pathology/physiology; best demonstrated by clinical experience in hospital setting.
• 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; ability to write concisely and effectively when communicating with providers.
• 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.
• Demonstrates knowledge of the importance of, and makes an effort to capture, all appropriate secondary diagnoses for quality rating purposes.