CDI Nurse

Medix is currently hiring for a RN Clinical Documentation Improvement Specialist for a Home Care Department of the healthcare organization. This large, Medicare-certfied home health agency that provides multidisciplinary skilled serviced in Burlington, Camden and Cloucester counties. We are seeking a Registered Nurse with prior home health experience, OASIS and experience in ICD-10 coding.

This position is onsite Monday - Friday.

Job Overview

The Clinical Documentation Improvement Specialist (CDIS) is responsible for competency in coordinating
and performing day to day operations, providing concurrent and/or retrospective review, and improving
documentation of all conditions, treatments, and care plans to ensure highest quality of care is provided to the patient. The CDIS will also education clinical staff in appropriate documentation criteria.

• As a Clinical Documentation Improvement Specialist, you will utilize your OASIS and coding expertise to guide, train and support home health clinicians in completing required documentation
• As a member of the Home Care team, you will also have the opportunity to participate in performance improvement activities
• Evaluates and analyzes medical records concurrently for proper documentation
• Collaborates with HIM Coders, clinicians and medical staff to ensure timely and accurate documentation that supports the diagnosis and treatment of the patient
• Collaborates with Physicians, Medical Directors, Quality Directors, Case Managers, Nurse Directors and Assistant Nurse Managers on cases that are not meeting standards and assists with the development of action plans to improve outcomes
• Evaluates and analyzes medical records concurrently for proper documentation
• This review includes new admissions to the facility, as well as re-reviews every two - three days until the patient is discharged
• Manages and trends data collection for an assigned hospital / facility/ specialty
• The CDI Specialist is the primary source to verify diagnoses in the medical record for proper DRG coding
• When symptoms in the medical record require further documentation, the CDI Specialist queries the physician for a specific diagnosis/procedure for more accurate DRG coding
• Collaborates with HIM Coders, clinicians and physicians to ensure documentation that supports the diagnosis and treatment of the patient is timely and accurate documentation
• Provides on-going training and education to the clinicians and physicians during 1:1, physician group, performance improvement and ad hoc meetings
• Collaborates with Quality and Case Management Department by reviewing medical records that are not meeting standards, and assists with the development of action plans to improve documentation for peer review of medical and nursing staff's documentation

• RN license required
• 2 years of Home Health experience preferred
• Must demonstrate the ability to accurately use a computer and standard office software such as Microsoft Excel, Word, Access and Power Point
• OASIS Experience

Medix is acting as an Employment Agency in relation to this vacancy.