RN CDI Specialist | Clinical Documentation Integrity
Washington, DC, United States
The CDI RN Specialist will ensure overall quality and completeness of clinical documentation for specified populations. Will facilitate modifications to clinical documentation through concurrent interaction with physicians and other members of the healthcare team to support (1) the appropriate severity of illness, (2) expected risk of mortality, and (3) complexity of care rendered to inpatient populations.
All nursing practice is based on the legal scope of practice, national and specialty nursing standards, Children's National Policies and Procedures, and in accordance with all applicable laws and regulations. The Professional Model of Care requires registered professional nurses to be responsible and accountable for their own practice.
Qualifications:
Minimum Education
BSN (Required)
Minimum Work Experience
5 years Experience with at least 3 years in clinical nursing. (Required)
Functional Accountabilities
Professional Practice/Research Participate in Shared Leadership.
Contribute to the MAGNET Journey of Children's National.
Ensure that nursing practice is based on evidence of best practices.
Accountable to participate in the Nursing Division's Performance Improvement process (division or unit level).
Participate in community activities.
Clinical Documentation 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.
Apply nationally recognized criteria to support physician queries; address delays in closing of physician queries with the appropriate departmental and leadership individuals.
Coordinate daily evaluation of documentation by the medical staff and/or healthcare team in accordance with Children's National policies and procedures.
Program Activities Target activities to specific payers, DRGs, and teams based on financial and clinical data analysis.
Collect and analyze data on program efforts and outcomes; identify patterns, trend variances, and opportunities to improve documentation review and process.
Assist in the development and reporting of performance measures to the medical staff and/or healthcare teams; prepare physician specific data reports.
Ability to follow-up on previous cases reviewed and prioritize work.
Facilitate change process required to capture needed documentation such as template/forms design.
Develop physician/provider education strategies to promote complete and accurate clinical documentation and correct negative trends.
Communicate Communicate verbally with physicians and/or healthcare team in a clear, timely, accurate, and professional manner.
E-mail communication conveys clear, timely, accurate, and pertinent information in an organized professional format.
Performance Improvement Ensure all physician queries are in compliance with federal regulations.
Identify opportunities for system-wide documentation improvement activities.
Promote the development of accurate and complete clinical documentation with physicians and other members of the healthcare team.
Active participation on departmental and/or hospital committees as assigned.
Educate members of the patient care team regarding specific documentation needs; education team members about reporting and reimbursement issues identified through concurrent/ retrospective documents review and aggregate data analysis.
Organizational Accountabilities
Organizational Accountabilities (Staff)
Organizational Commitment/Identification Anticipate and responds to customer needs; follows up until needs are met
Teamwork/Communication Demonstrate collaborative and respectful behavior
Partner with all team members to achieve goals
Receptive to others' ideas and opinions
Performance Improvement/Problem-solving Contribute to a positive work environment
Demonstrate flexibility and willingness to change
Identify opportunities to improve clinical and administrative processes
Make appropriate decisions, using sound judgment
Cost Management/Financial Responsibility Use resources efficiently
Search for less costly ways of doing things
Safety Speak up when team members appear to exhibit unsafe behavior or performance
Continuously validate and verify information needed for decision making or documentation
Stop in the face of uncertainty and takes time to resolve the situation
Demonstrate accurate, clear and timely verbal and written communication
Actively promote safety for patients, families, visitors and co-workers
Attend carefully to important details - practicing Stop, Think, Act and Review in order to self-check behavior and performance
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