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RN - Clinical Documentation Integrity Specialist



Urbana, IL, USA
Posted on Tuesday, September 12, 2023

Job Description


Position Highlights:

  • 8 hospital system in Central Illinois including a level I trauma center
  • Centralized CDI leadership
  • Dedicated Physician Advisor resources for CDI
  • Availability to work remotely
  • Collaborative team of CDI professionals
  • Sign on bonus
Performs inpatient chart review to determine appropriate DRG assignment and assures appropriate documentation in the chart to support clinical care provided, including severity of illness and risk of mortality which impacts Case Mix Index and mortality ratings. Coordinates with physicians, nurses, ancillary staff, and the coders in Health Information Management to identify and record principal and secondary diagnoses, principal procedures, and assign the working DRG. Performs second level review of specific DRGs as assigned. Presents education related to CDI topics to peers and providers we needed or requested.

Associate's Degree in Related field

Registered Professional Nurse (RN) License State of IL Nursing License required within 6 months of hire if licensed in another state within 6 months or Registered Health Information Admin (AHIMA) upon hire.

Two (2) to five (5) years Clinical bedside experienceTwo (2) years CDI experience

Requires excellent organizational and communication skills. Demonstrated ability to work as an active member. Up to date clinical skills preferred; need to have current working knowledge of pathology, managed care, healthcare quality, and reimbursement. Excellent computer skills, including knowledge of word, excel and power point.

  • Conducts the initial concurrent review process for all selected admissions
  • Clarifies documentation in the medical record as appropriate through communication with the physicians, nurses, and ancillary staff. Assures documentation in chart represents a true clinical picture of the patient diagnoses and supports care that was given and DRG assigned
  • Documents findings within Carle CDI software and updates software as required to reflect status of the encounter and any follow up
  • Coordinates with the physicians, nurses, ancillary hospital staff, and Health Information Management Department's coding staff to identify and record principal and secondary diagnoses, principal procedures, and assign the working DRG
  • Follows query process and escalates as necessary
  • Conducts education related to CDI topics to peers and providers as needed or requested
  • Performs second level review on selected inpatient encounters
  • Reviews denials for accurate and complete documentation and develops appeal letter when needed
  • Attends mandatory and regular education sessions as needed
  • Follows appropriate workflow in EPIC and CDI software and notifies one up leader of any issues
  • May serve as an "expert" and participate in testing for upgrades as needed