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Clinical Documentation Improvement Spec

Company Name:
Aspirus
Clinical Documentation Improvement Spec
Category: Professional/Technical
Facility: Aspirus Wausau Hospital
Location: Wausau, WI
Department: Aspirus Wausau Hospital - Clinical Documentation
Schedule: Full Time
Shift: Day
Req Number: 7747
Job Details: Licensure
The Clinical Documentation Improvement Specialist (CDI) communicates with the healthcare team regarding missing, unclear, or conflicting medical record documentation in an effort to clarify and obtain the documentation that will support the appropriate severity of illness, expected risk of mortality and complexity of care. Medical record review will assure that clinical documentation:
Correlates with available procedure and diagnosis codes;
Supports assignment to the proper DRG;
Maximizes reimbursement;
Results in the assignment of an appropriate risk of mortality score.
Education
Knowledge of patient care standards and practices normally acquired through completion of a nursing program. Bachelor s Degree in Nursing preferred.
Experience
Minimum of two years acute care hospital experience.
Experience in critical care, general medical and/or surgical nursing, and experience in educational presentations beneficial.
Previous experience with criteria-based chart review such as case management, utilization management, managed care, or quality improvement.
Clinical documentation improvement experience with knowledge and/or experience related to ICD code assignment and DRG assignment preferred.
Required
Possesses an active Wisconsin RN nursing license.
Other
Active membership in a professional organization beneficial.
Possesses strong clinical skills, assessment and good professional judgment, as well as broad-based knowledge of medical management and nursing management.
Demonstrates familiarity and knowledge of medical record organization and procedures.
Possesses general understanding and knowledge of performance improvement principles.
Basic computer skills.
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