Registered Nurse CDI Specialist

Evaluates patients' medical records for appropriate documentation of all appropriate diagnoses. Utilizes clinical knowledge and coding guidelines to establish the appropriate diagnoses, reviews clinical reports and physician orders to identify undocumented conditions relative to the current hospitalization. Talks to and educates the physicians treating the patient on accurate and timely documentation of those conditions. in order to obtain, clarify or correct clinical documentation. Tracks case mix data to identify opportunities for documentation improvement in key areas. Works closely with coding department to insure concise and accurate documentation to support an accurate coding representation of patients clinical picture.

Responsibilities

Knowledge, Skills & Abilities

Patient Group Knowledge (Only applies to positions with direct patient contact)

The employee must possess/obtain (by the end of the orientation period) and demonstrate the knowledge and skills necessary to provide developmentally appropriate assessment, treatment or care as defined by the department’s identified patient ages. Specifically the employee must be able to demonstrate competency in: 1) ability to obtain and interpret information in terms of patient needs; 2) knowledge of growth and development; and 3) understanding of the range of treatment needed by the patients.

Competency Statement

Must demonstrate competency through an initial orientation and ongoing competency validation to independently perform tasks and additional duties as specified in the job description and the unit/department specific competency checklist.

Common Duties and Responsibilities
(Essential duties common to all positions)

1. Maintain and document all applicable required education.
2. Demonstrate positive customer service and co-worker relations.
3. Comply with the company's attendance policy.
4. Participate in the continuous, quality improvement activities of the department and institution.
5. Perform work in a cost effective manner.
6. Perform work in accordance with all departmental pay practices and scheduling policies, including but not limited to, overtime, various shift work, and on-call situations.
7. Perform work in alignment with the overall mission and strategic plan of the organization.
8. Follow organizational and departmental policies and procedures, as applicable.
9. Perform related duties as assigned.

Education

• Bachelor's Degree (Required) Experience: 5 - 7 YEARS Acute Care or Critical Care Nursing Experience SUBSTITUTION: Associate Degree in Nursing with 7-10 years Acute Care or Critical Care Nursing Experience. May substitute for Bachelor Degree in Nursing.

Credentials

Work Schedule: Days

Status: Full Time Regular 1.0

Location: Document Center Building

Location of Job: US:WV:Charleston

Talent Acquisition Specialist: Lauren R. Lane lauren.lane@vandaliahealth.org