25 days old

Clinical Documentation Specialist RN - Wilmington

Nemours
Wilmington, DE 19801
  • Job Code
    2936
The Clinical Documentation Specialist RN responsible for review of outpatient medical records, analysis of documentation of clinical diagnoses using ICD 10 criteria with the goal of identifying conflicting diagnoses, gaps in clinical documentation, unspecified diagnoses and missing diagnoses. The CDI RN will clarify these diagnoses with providers and educate them to improve medical record accuracy and integrity. The CDI RN will provide education of ICD 10 specificity and chronic comorbidity capture for attending, primary care, and resident physicians as well as advanced practice nurses. Assist in developing successful strategies to capture accurate health status of our outpatient population. Be a resource for outpatient coding staff regarding clinical knowledge of conditions and diagnosis specificity, while supporting IT development of templates, databases, other documentation tools in conjunction with patient care team. The CDI RN will support CI/QI efforts within the organization, assisting with problem list clean up and research documentation.

Qualifications:

  • Extensive knowledge of medical terminology, anatomy, physiology, pharmacology and disease processes
  • Registered Nurse preferably with Pediatric nursing and/or CDI experience
  • Delaware RN license
  • Minimum of 5 years experience in nursing
  • CDI certification and/or coding certification preferred

Primary Responsibilities:
  • Responsible for review of outpatient medical records, analyze documentation of clinical diagnoses using ICD 10 criteria. Goal to identify conflicting diagnoses, gaps in clinical documentation, unspecified diagnoses, missing diagnoses and use clinical validation to clarify these diagnoses with providers.
  • Maintain chart integrity with accurate and specific diagnoses. Maintain current knowledge of changes in diagnosis requirements for specificity around ICD changes.
  • Educate and support the need to document for risk stratification in the primary care offices.
  • Education of ICD 10 specificity and documentation requirements for attending and resident physicians, medical students, advanced practice nurses and clinical nurses.
  • Resource for hospital coding staff re: clinical knowledge of conditions and diagnosis specificity.
  • Collaborate with coding integrity and physician abstractors in delivering documentation education to providers including education of risk stratification, chronic conditions, and appropriate documentation to support billing.
  • Support IT development of templates, databases, other documentation tools in conjunction with patient care team. Support CI/QI efforts within the hospital, assisting with gathering of HAI/HAC and research documentation.
  • Inpatient medical review as indicated with same goals.
  • Review outpatient medical records for documentation opportunities and problem list accuracy. Analyzes clinical status of patient, current treatment plan and past medical history and identifies potential gaps in physician documentation
  • Attend multidisciplinary patient rounds with care team
  • Communicate with care team regarding documentation opportunities and ICD 10 specificity-verbal or written clarifications and track this data in electronic repository identified for CDI. Verify the response from care team to clarification of diagnosis
  • In collaboration with physician leadership, designs and implements specific tools, templates and educational programs to support medical record physician documentation
  • Identify and arrange education for new providers soon after onboarding- develop educational offerings for new providers
  • Identify trends/opportunities for improvement in documentation habits of service line and report that information to the attending group in education session
  • Expert knowledge of EHR use and tools available for clarification presentation and tracking
  • Maintain expert knowledge of current changes of ICD 10 requirements and HEDIS measures and educate providers to needed changes in documentation
  • Identifies strategies for sustained work process changes that facilitate complete and accurate clinical documentation.
  • Maintain open communication with coding staff, CDS and CDI physician liaison to accurately reflect the diagnoses
  • Actively seek new opportunities to review records and offer documentation education and advice-inpatient, ED, outpatient specialty and primary care clinics
  • Active involvement in post coding review of charts for accurate reflection of diagnosis coding






Posted: 2021-12-26 Expires: 2022-01-24
Sponsored by:
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Clinical Documentation Specialist RN - Wilmington

Nemours
Wilmington, DE 19801

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