RN Clinical Documentation Integrity Spec

Schedule: Full-time

Job Summary:

This licensed professional nurse (RN) works with the Medical Staff to offer documentation education to ensure an accurate and complete medical record with documentation that allows for codeable diagnosis and/or procedures. He/she works within the scope of the HIM Department to provide documentation that best represents the patient's clinical findings and treatment plan. This professional is also responsible for data quality review on specified records, resolution of DRG/APG/ASC coding changes with third party payers and provides structured education programs. The candidate must be able to follow standard practices in

coding/reimbursement and to optimize payment for all financial schemes. He/she must demonstrate exceptional judgment and organizational ability and possess excellent communication skills, both written and oral.

Education:

Required: Registered Nurse in the state of TN,

Preferred: BSN. MSN

Experience:

Required: The candidate must have a strong clinical background (minimum of five years bed side nursing). Must be computer literate with experience in Microsoft Office and/or Excel.

Preferred: The candidate would have an understanding of reimbursement principles and/or coding concepts. Experience with 3M 360

Position requirements/Licensure:

Required: Current license to practice nursing in the State of Tennessee.

The Nurse Licensure Compact will not change how to obtain or renew a Tennessee license. However, the Tennessee nursing license will be a single state license for Tennessee Residents or non-compact state residents. Tennessee licensure or multistate licensure from a compact state must be obtained within three months of hire for non-Tennessee residents.

Preferred: CCDS or CDIP

Department Position Summary:

Responsible for communication with the medical staff to improve the quality and clarity of documentation of patients condition in the medical record. Reduces physician's workload through assistance with regulatory guides through clinical review. Supports documentation of clinically supported procedures.

When documentation is incomplete, vague, or ambiguous, it is the responsibility of the CDI nurse to utilize the appropriate physician clarification process to obtain additional information that provides a codeable diagnosis, procedure. Reviews inpatient medical records to assign and sequence all appropriate diagnosis and procedures codes utilizing encoder software and proficiently translating diagnostic statements, physician orders, and other pertinent documentation. Reviews Medicare Severity Diagnosis Related Groups (MSDRGs) and All Patient Refined Diagnosis Related Groups (APRDRGs) on inpatient cases. Reviews appropriate CDI work lanes daily to address coding edits and needed corrections and follows procedure as needed to resolve these cases. Reviews accounts and performs needed correction for internal audits.

This position may be assigned 2nd level review cases based on defined department processes. The CDI nurse will review these cases and follow department process for communication on missed findings.

The employee must be detail oriented and able to assimilate large quantities of data, analyze the data and provide organized reports on the data. The employee must be able to demonstrate knowledge of problem identification and resolution. The individual must demonstrate the ability and desire to learn intense optimization techniques. The employee must be able to research data gathered and organize the data into a comprehensive educational presentation. The individual must have the professional demeanor needed to present education programs to various audience types. The individual must demonstrate flexibility in the scope and type of work assigned.

The employee in this position must display the ability to be self-motivated, able to evaluate the scope of each day's work and display time management skills to accomplish the work evaluated. The employee must keep her/his licensure current by participating in continuing education.

Other responsibilities include:

- Adherence to Health Information Management (HIM) Coding and CDI policies.

- Interprets and applies American Hospital Association (AHA) Official Coding Guidelines to articulate and support appropriate principal, secondary diagnoses and procedures.

- Adherence to Det Norske Veritas (DNV) and other third-party documentation guidelines in an effort to continually improve coding quality and accuracy.

- Responsibility for maintaining knowledge referencing current diagnosis and procedural coding, coding guidelines and regulatory changes.

- Contacts the appropriate department or physician for assistance in obtaining physician clarification of diagnoses.

- Participates in performance improvement initiatives as assigned.

This position must consistently meet or exceed productivity and quality standards as defined by department Leadership.