POSITION SUMMARY

The Clinical Documentation Integrity (CDI)  RN is responsible for improving overall quality and completeness of clinical documentation to accurately reflect the provider intensity of service, patient severity of illness and overall risk of mortality through extensive interaction with physicians, case management, nursing staff, and other patient caregivers and coding staff.

The CDI RN will initiate concurrent and/or retrospective clinical medical record reviews for hospital patients. Will monitor them and perform systematic review to determine compliance to established documentation standards and billing/coding/reporting/query guidelines. The CDI RN will conduct follow-up reviews as necessary. The CDI RN level 2 role requires full working knowledge of basic and 

intermediate CDI and Coding, concepts, and methods and the ability to apply established practices and concepts to perform professional work. Proficiency in the use of CDI and coding systems, CDI/coding concepts and data analysis.

This position supports organizational goals by providing quality customer service, participating in performance improvement efforts and demonstrating a commitment to team work and cooperation.

QUALIFICATIONS

EDUCATION: Graduate of an accredited school of nursing required.  Bachelor’s in Nursing required.  

LICENSE/CERTIFICATION: Current licensure as a Registered Nurse in the State of New Jersey/Nursing Compact state required.

EXPERIENCE:  5 years relevant clinical experience required.  3 years recent hands-on experience as inpatient Clinical Documentation Integrity (CDI) RN required.  Prior experience with coding, CDI and query guidelines and chart review required. Ability to work independently and use good judgment in decision making. Excellent leadership, interpersonal, written communication skills and computer literacy required as well as analytical and delegation skills.  Proficiency in Clinical Applications preferred at time of hire; incumbents within position will be trained appropriately and then skill will be required for this position within 30-60 days from date of hire.

PERFORMANCE EXPECTATIONS

Demonstrates the technical competencies as established on the Assessment and Evaluation Tool.

WORK ENVIRONMENT

Potential for exposure to the hazards and risk of the hospital environment, blood borne pathogens, including exposure to infectious disease, hazardous substances, and potential injury.  This position requires frequent walking and standing.

The essential functions for this position are listed on the Assessment and Evaluation Tool.

REPORTING RELATIONSHIP

This position report to Department Leadership and may supervise incumbents’ as assigned.

The above statement reflect the general details considered necessary to describe the principle functions of the job as identified and shall not be considered as a detailed description of all work requirements that may be inherent in the position.