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Clinical Documentation Improvement Specialist Registered Nurse (RN)
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- A highly successful CDI program is based on a highly interactive process between physicians, CDIS staff and other support services.
- Provides education to the medical staff and other clinical professional on documentation relevant to the Revenue Management processes and Discharge Not Final Billed reduction.
- It is expected that the CDIS have previous clinical skills, including an understanding of Anatomy and Physiology in order to appropriately discuss with the physician such issues as the underlying etiology, principal diagnosis, diagnostic studies, treatment modalities, to name a few.
- Job Duties:Reviews inpatient medical records within 24-48 hours of admission for a specified patient population toevaluate documentation to assign the principal diagnosis, relevant secondary diagnoses, and procedures for accurate DRG assignment, risk of mortality, severity of illness; and initiate documentation of the review.
- Pursues a subsequent review of records every 3 days to support and assign a working DRG assignment upon discharge.
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