Assists treating providers to ensure documentation in the medical record accurately reflects the severity of illness of the patient as well as the level of service rendered.
Uses clinical/nursing knowledge and understanding of national coding guidelines and standards of compliance to improve overall quality and completeness of clinical documentation within the patient electronic medical record.
Works collaboratively with physicians and advanced practice providers to ensure the clinical information within the medical record is accurate, complete, and compliant.
Educates members of the patient care team regarding documentation guidelines, coding requirements and service specific requirements.
Reviews selected populations of inpatient medical records to identify the principal and/or secondary diagnoses.
Appropriately assigns the MS-DRG that most accurately reflects the severity of illness of the patient based upon the clinical evidence documented at the time of the record review.
Demonstrates knowledge and understanding of severity based DRG systems.

Registered Nurse North Carolina Licensure required.
Bachelor's Degree Required.
Appropriate professional certification required within 3 years of hire date per department protocol.
5 years of related nursing experience preferred.
Clinical experience within the assigned population.
Extensive knowledge of disease processes and clinical outcomes.
Case Management experience or background helpful.
Strong financial and analytical skills preferred.
Word, Outlook, Excel experience preferred.

Health and welfare benefits such as medical, dental, vision, life, and Short
and Long-Term Disability
Flexible Spending Accounts for eligible health care and dependent care expenses
Family benefits such as adoption assistance and paid parental leave
Defined contribution retirement plans with employer match and other financial wellness programs
Educational Assistance Program
Paid Time Off programs

RN – Clinical Documentation Improvement Specialist

About this role