RN Clinical Documentation Specialist

Clinical Documentation Improvement Second Level Reviewer

The Clinical Documentation Improvement Second Level Reviewer is a Professional Registered Nurse with a broad clinical knowledge base and understanding of DRG documentation requirements who works under the supervision of the CDI Manager. Responsibilities include secondary clinical chart reviews, resolution of DRG discrepancies, and education to clinical staff regarding opportunities for diagnosis clarification, principal diagnosis accuracy, and improvement of capture of additional comorbid conditions diagnoses. The Clinical Documentation Improvement Second Level Reviewer will conduct concurrent and retrospective medical record review for defined patient populations to identify opportunities to improve accuracy of practitioner documentation; collaborate with Case Management and Coding department to assure documentation is clinically appropriate, and accurately reflect the severity of illness for the patient that is reflective of current CMS standards.

Education:

• Associates, Diploma or Bachelor's degree in Nursing

Licenses and Certification:

• Current Illinois RN license required
• Certification in Clinical Documentation Improvement or Coding preferred

Experience and Skills:

• Technical Experience: 2 years

Must be able to demonstrate broad clinical knowledge base necessary to review a wide variety of medical records.

Must be able to demonstrate positive communications skills.

Role Specific Responsibilities:

• Completes secondary reviews of targeted patient populations to identify missed opportunities and accurate selection of principal diagnosis.
• Acts as a liaison between the Coding Department and the Clinical Documentation Specialist to reconcile discrepancies in DRG assignment.
• Communicates findings of secondary reviews to respective Clinical Documentation Improvement Specialists and Coding staff for follow up.
• Documents and tracks secondary review data. Shares this information with staff at monthly DCI meetings.
• Completes medical record review using an organized approach to survey admit notes, past medical history, home meds, physician/provider documentation, treatments, orders, ancillary department notes, laboratory data and other pertinent components of the clinical record.
• Analyzes and interprets clinical data to identify gaps, tends, inconsistencies and/or opportunities for improvement in the clinical documentation.
• Regularly interacts with/educates physicians to enhance understanding of the CDI program and to insure the medical record can be coded accurately in order to reflect patient severity of illness and risk of mortality.
• Collaborates with other clinical disciplines and members of the coding department to insure high quality clinical documentation and efficient, timely coding of the medical record.

Collaborates with Coding Department when discrepancies in the medical record are identified and reviews medical record to provide clinical feedback for accurate coding.

Develops collaborative relationships and promotes team work with co-workers and other departments.

Organizes and performs work responsibilities effectively and efficiently.

Maintains strict patient confidentiality, adhering to HIPPA guidelines.

Compensation (Commensurate with experience): $67,475.20 - $104,582.40

To access our Benefits Guide/Plan Information, please click the link below:

http://www.sih.net/careers/benefits