Job Description
This position requires Registered Nurse license with the FL Board of Nursing. The position requires onsite work at the facility.
Nemours is looking for a Clinical Documentation Specialist - Registered Nurse. The Clinical Documentation Specialist (CDI RN) is 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. Inpatient medical review as indicated with same goals.
Primary Responsibilities: - 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
- Partners with providers and administrative staff to support Risk Adjustment initiatives. Leverages technology to identify gaps in Risk recapture
- Uses EHR tools to support risk-adjustment clinical documentation integrity initiatives in collaboration with
- Educates staff and providers on documentation principles and assists in communicating program metrics through dashboards and various reports.
- 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
Requirements: - Must have at least 5 years pediatric nursing experience.
- BSN required
- CDI certification and/or coding certification preferred
- Licensed registered nurse
- Extensive knowledge of medical terminology, anatomy, physiology, pharmacology, and disease processes
- Registered Nurse preferably with Pediatric nursing and/or CDI experience
- Minimum of 5 years' experience in pediatric nursing
Job Tags
Permanent employment,