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EL Instructional Development Specialist, OLCE
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- Description: The CDI RN Specialist will ensure overall quality and completeness of clinical documentation for specified populations.
- Accountable to participate in the Nursing Division’s Performance Improvement process (division or unit level).
- Provide daily clinical evaluation of the medical record including physician and clinical documentation, lab results, diagnostic information, and treatment plans.
- Collaborate with Coder CDI Specialist in regard to interaction with physicians on documentation, and to resolve physician queries prior to patient discharge.
- Communicate with physicians (face-to-face or via clinical documentation inquiry forms) regarding missing, unclear, or conflicting medical record documentation; work with providers to ensure accurate and complete documentation is in the patient record.
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