CLINICAL DOCUMENTATION IMPROVEMENT RN (CDI)

Southwest General Health Center is a 352-bed community hospital located in Middleburg Heights, Ohio. One of the last standing community hospitals in Northeast Ohio, we partner with University Hospitals and other local community organizations to provide a full range of services to all who need us. We are certified as a Level III Trauma Center and a Primary Stroke Center, and have been serving our community for over 100 years!

Why work at SWGHC? In addition to the outstanding culture, we offer great benefits, no rotating shifts, free parking and are close to the turnpike and I71. Come join our team! #loveajobthatlovesyouback

CLINICAL DOCUMENTATION IMPROVEMENT NURSE

POSITION SUMMARY :

The Clinical Documentation Improvement (CDI) nurse is responsible for facilitating the improvement in the overall quality and completeness of provider-based clinical documentation in the medical record. This position will be responsible for assisting treating providers to ensure that documentation in the medical record accurately reflects the patient’s clinical presentation as well as the level of services rendered. The CDI nurse assesses clinical documentation through extensive review of the medical record, interaction with physicians, nursing staff, other patient caregivers, and Health Information Management (HIM) coding staff. The CDI nurse ensures the medical record accurately reflects the patient's diagnosis, treatment, severity of illness, and risk of mortality.

Principal Duties and Responsibilities

1. Facilitates appropriate clinical documentation to support appropriate diagnosis coding and to ensure the level of service rendered to all patients is recorded.

2. Collaborates with HIM coding staff to promote complete and accurate clinical documentation.

3. Communicates with physicians, nurse practitioners, physician assistants, coders and other members of the care team to facilitate comprehensive medical record documentation to reflect treatment, decision-making and medical documentation.

4. Assigns a working APR-DRG and severity level using coding rules and guidelines with follow up reviews until SOI and ROM are 4 / 4.

5. Analyze clinical information to identify areas within the chart for potential gaps in physician documentation.

6. Queries physicians on a concurrent basis. Works with physicians to clarify documentation in the medical record.

7. Formulate compliant clinical documentation clarifications to improve clinical documentation of principal diagnosis, co-morbidities, present on admission (POA), quality core measures, and patient safety indicators (PSI).

8. Conducts post discharge reviews for comparative analysis of CDI Specialist and HIM APR-DRG and severity level assignment. Reviews clinical documentation with the coding staff to assign a working DRG.

9. Develops and conducts ongoing education for new staff, including new CDI Specialists, physicians and nursing.

10. Utilizes CDE One software systems (including APR-DRG encoder) to collect, track, and report outcomes. Requires proficiency in abstracting and data entry into all databases used for clinical documentation. Maintains integrity of data collection.

11. Participates in ongoing education of staff. Develops educational material and tools relative to documentation improvement practices for individual practitioners and groups of clinicians presented as handouts, PowerPoint, etc.

Minimum Qualifications

Education : Graduate of an accredited school of nursing and current RN licensure by Ohio State Board of Nursing, Bachelor’s degree preferred.

Required length of experience : Minimum of 5 years hospital floor experience as an RN. Must pass a clinical pre-hire written assessment at 70% or better. Work requires superior interpersonal skills and demonstrated ability to communicate effectively with physicians and providers is essential.

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