Clinical Documentation Integrity RN/LPN New

Location: Chicago, IL, USA

Salary: $40.00 USD Hourly - $45.00 USD Hourly

Description

Job Title: Clinical Documentation Improvement (CDI) Nurse (RN or LPN)

Job Summary: The Clinical Documentation Improvement (CDI) Nurse leverages expertise in clinical care and medical coding to conduct concurrent and retrospective reviews of inpatient and outpatient medical records. The primary objective is to enhance the quality and accuracy of clinical documentation, with a focus on critical areas identified by CDI leadership, such as mortality reviews and patient safety indicator (PSI) reviews.

Essential Functions

• Review clinical documentation to accurately reflect severity of illness, risk of mortality, and care complexity.
• Communicate review findings and recommendations to leadership, CDI Specialists, and other staff.
• Conduct targeted reviews in priority areas identified by CDI leadership.
• Develop and deliver educational sessions for CDI specialists, physicians, and related departments regarding documentation trends and best practices.
• Provide ongoing education to healthcare providers on documentation improvement methods.
• Standardize and evaluate CDI review findings to ensure accuracy and consistency.
• Analyze trends, variances, and deficiencies using aggregated data to drive improvements.
• Monitor the effectiveness of concurrent medical record reviews and query processes.
• Collaborate with the CDI Director, HIMS coding, Quality, and Compliance teams to ensure accurate diagnostic and procedural data.
• Serve as a subject matter expert on clinical documentation practices, coding rules, and regulations.
• Assign working DRGs in adherence with hospital policies and federal/state guidelines.
• Partner with physicians to obtain additional documentation as needed to ensure clarity and completeness.
• Coordinate efforts with HIMS coding staff to maintain accurate and comprehensive diagnostic and procedural data.
  
  

Minimum Requirements

• Bachelor’s degree in Nursing.
• Minimum of five years of progressive clinical work experience.
• At least three years of experience as a Clinical Documentation Improvement Specialist.
• Familiarity with MS-DRG and APR-DRG review processes.
• Preferred: At least one year of supervisory experience and/or experience with quality outcomes-focused CDI reviews.
  
  

Licenses/Certifications

• Active RN or LPN license.
• CCDS certification through ACDIS (required).
  
  

Skills And Competencies

• Strong analytical skills to evaluate clinical documentation and identify areas for improvement.
• Excellent communication and presentation abilities to educate and collaborate with diverse healthcare teams.
• In-depth knowledge of medical coding guidelines, hospital policies, and regulatory requirements.
• Ability to identify and address trends, variances, and deficiencies in documentation practices.
  
  

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