Telecommute – US National
Title:CDQI Nurse Specialist
Location:United States -Remote
The Clinical Documentation Quality Improvement (CDQI) Specialist performs daily evaluations of medical record documentation to include provider notes, lab results, diagnostic information and treatment plans, and communicates with providers face-to-face or via query forms to clarify or obtain the missing, unclear or conflicting documentation. The clarified physician documentation within the medical record results in the support of the overall quality and completeness of the medical record documentation for code assignment.
Duties and responsibilities:
Demonstrates an understanding of complications, co-morbidities, severity of illness, risk of mortality, case mix index, secondary diagnoses, and the impact of procedures on the final Diagnosis Related Group (DRG).
Performs timely, accurate and complete documentation reviews of selected inpatient records to clarify conditions/diagnoses and procedures in which inadequate or conflicting documentation exists.
Collaborates with physicians and other patient caregivers to support that appropriate reimbursement and clinical severity is captured for the level of service rendered to all patients with a DRG based payer.
Improves coding specificity by educating physicians, clinicians, and other involved parties regarding the necessity of providing complete and clear documentation of the care provided throughout a patient’s stay.
Follows AHA guidelines and coding clinics for coding and required documentation to ensure physician and hospital compliance. Remains current with coding information to ensure accuracy of codes assigned based on documentation.
Queries physicians or physician extenders regarding missing, unclear, or conflicting health record documentation by requesting and obtaining additional documentation within the health record when needed.
Keeps daily production logs containing number of cases reviewed, number of queries placed/responded, etc. for weekly evaluation of output.
Conducts follow-up reviews of clinical documentation to ensure points of clarification have been recorded within the patient’s medical record.
Maintains and keeps in total confidence, all files, documents and records.
Meets or exceeds production and quality metrics.
Performs all other job-related duties as it relates to job function as delegated by management
Minimum Education: Registered Nurse, CCDS or CDIP certification
Preferred Experience: Bachelors in Nursing Minimum
Experience: 3 years CDI experience, 3 years of clinical experience in an academic medical center.
Must pass a CDI skills competency assessment.
Administrative,Medical & Health,Medical Coding,Nursing,Research