CDI RN Specialist - Omaha, NE - Hybrid
Tenet Healthcare
- Omaha, NE
- Permanent
- Full-time
- Record Review: Completes initial medical records reviews of patient records within 24-48 hours of admission for a specified patient population to: (a) evaluate documentation to assign the principal diagnosis, pertinent secondary diagnoses, and procedures for accurate MS-DRG assignment, risk of mortality and severity of illness; and (b) initiate a review worksheet.
- Conducts follow-up reviews of patients every 2-3 days to support and assign a working or final MS-DRG assignment upon patient discharge, as necessary.
- Formulate physician queries regarding missing, unclear or conflicting health record documentation by requesting and obtaining additional documentation within the health record, as necessary.
- Collaborates with case managers, nursing staff and other ancillary staff regarding interaction with physicians regarding documentation and to resolve physician queries prior to discharge.
- Assist in training department staff new to CDI
- Professional Development: Stays current with AHA Official Coding and Reporting Guidelines, CMS and other agency directives for ICD-9-CM and CPT coding. Attends mandatory coding seminars on annual basis (IPPS and OPPS, ICD-9-CM and CPT updates) for inpatient and outpatient coding. Quarterly review of AHA Coding Clinic. Attends Quarterly Coding Updates and all coding conference calls as well as any required CDI education.
- CDI: Communicates/Completes Clinical Documentation Improvement (CDI) activities and coding issues (lacking documentation, physician queries, etc.) for appropriate follow-up and resolution
- Other duties as assigned
- CDI Specialist must display teamwork and commitment while performing daily duties
- Must demonstrate initiative and discipline in time management and medical record review
- Travel may be required to meet the needs of the facilities
- Advanced knowledge of Medicare Part A and familiar with Medicare Part B
- Intermediate knowledge of disease pathophysiology and drug utilization
- Intermediate knowledge of MS-DRG classification and reimbursement structures
- Critical thinking, problem solving and deductive reasoning skills
- Effective written and verbal communication skills
- Knowledge of coding compliance and regulatory standards
- Excellent organizational skills for initiation and maintenance of efficient work flow
- Regular and reliable attendance and time reporting per Conifer Telecommuting program requirements
- Capacity to work independently in a virtual office setting or at facility setting if required to travel for assignment
- Understand and communicate documentation strategies
- Recognize opportunities for documentation improvement
- Formulate clinically, compliant credible queries
- Ability to maintain an auditing and monitoring program as a means to measure query process
- Ability to apply coding conventions, official guidelines, and Coding Clinic advice to health record documentation
- Preferred: Acute Care nursing relevant experience
- Zero (0) to two (2) years experience
- Graduate from a Nursing program, BSN, or graduate
- Active state Registered Nurse license
- Preferred: CDIP or CCDS
- Ability to sit for extended periods of time
- Must be able to efficiently use computer keyboard and mouse
- Good visual acuity
- Must be able to travel nationally as needed, not to exceed 10%