Clinical Documentation Specialist - Registered Nurse

• CDI Registered Nurse will be working onsite at the Hospital.

• Registered nurses will review our in-house Medicare cases. We will need them to identify the working DRG using the 3M encoder, write queries, do follow-up, and resolve any questions.

• The CDI Specialist is an integral part of the healthcare team and is responsible for ensuring that the patient record contains clinical documentation that is clear, concise, and clinically accurate to meet the goals of the CDI program. The CDI Specialist serves as part of the team responsible for improving the concurrent documentation practices in the hospital through ongoing education and works with physician clinical documentation, coding and reimbursement processes towards achieving quality and productivity goals.

• Knowledge of diagnoses/procedures in accordance with ICD-9 CM & CPT-4 coding principles

• Knowledge of all state, federal and private reimbursement systems

• Ability to analyze large amounts of date, and be a problem solver

• Ability to multi-task

• RN Lic in CA – Required

• Clinical experience in acute care environment- Required

• Experience in practice of clinical documentation; nursing health information, case management, quality management or similar related fields – Required

• Proficient in computer skills with many softwares including, but not limited to, charting softwares, MS Office Suite, Lotus Notes- Required

• Current CDI certification (must obtain within 18 months of employment through Association of Clinical Documentation Improvement Specialist/ACDIS)-Highly Desired

Excellent pay and opportunity at a large local hospital system. Interviewing and hiring right away