CDI RN Specialist | Clinical Documentation Integrity


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, ***** and specialty nursing standards, ***** ***** 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.

Roles Responsibility
Participate in Shared Leadership, Contribute to the MAGNET Journey of Children’s *****, 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, Provide daily clinical evaluation of the medical record including physician and clinical documentation, Collaborate with Coder CDI Specialist in regard to interaction with physicians on documentation, Communicate with physicians regarding missing, unclear, or conflicting medical record documentation, Apply *****ly recognized criteria to support physician queries, Coordinate daily evaluation of documentation by the medical staff and/or healthcare team, Target activities to specific payers, DRGs, and teams based on financial and clinical data analysis, Collect and analyze data on program efforts and outcomes, Assist in the development and reporting of performance measures to the medical staff and/or healthcare teams, Facilitate change process required to capture needed documentation, Develop physician/provider education strategies, Communicate verbally with physicians and healthcare team, E-mail communication conveys clear, timely, accurate information, Ensure all physician queries comply with regulations, Identify opportunities for system-wide documentation improvement, Educate members of the patient care team regarding specific documentation needs, Identify opportunities to improve processes, Use resources efficiently, Search for less costly ways of doing things, Speak up when team members exhibit unsafe behavior or performance, Continuously validate and verify information, Actively promote safety for patients, families, visitors, and coworkers, Attend to important details
Desired Qualification
BSN Bachelor of Science in Nursing
Full Time
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