Clinical Documentation Improvement Specialist

Duties:

Apply knowledge of medical terminology and procedures to evaluate clinical documentation in the EMR. Perform concurrent and/or retrospective chart review to ascertain specificity of diagnoses. Communicate with physicians to obtain documentation for optimal DRG assignment. Verify the accuracy of patient medical information and obtaining documentation that reflects comorbidities (cc), major morbidities (mcc) and quality care through the quality care through the Query process. Train medical staff in using the correct medical documentation and verbiage to reflect the Severity of Care (SOI) and the Risk of Mortality (ROM) in patients. Ensure that the content and storage of medical documents comply with federal laws.

NYS Licensed Registered Nurse with 5 years in an acute care setting. BSN required. CDI experience preferred. Knowledge of DRG assignment and ICD-10 coding clinical experience preferred. Familiarity in Electronic Medic...