Clinical Document Improvement Specialist at Cookeville Regional Medical Center – Cookeville, Tennessee

This position is responsible for reviewing medical records to facilitate appropriate physician documentation for any clinical conditions or procedures to support the appropriate severity of illness, expected risk of mortality, and complexity of care of the patient. Working with providers to improve the quality of clinical documentation,. Exhibits a sufficient knowledge of clinical documentation requirements, MS-DRG Assignments and clinical conditions or procedures. Educates members of the patient care team, regarding documentation guidelines, including all physician and extenders. .Ensures the timeliness of all written and verbal queries from providers to ensure proper documentations obtained and placed in the medical record before patient discharge. Maintains communication with physician office to provide education.

Additional Education Requirements

High School Diploma/GED required. Associate or Bachelors in Nursing, Health Information Management preferred.

Additional Experience Requirements

Three to five years registered clinical experience or CDI experience in similarly complex acute care setting. Familiarity with utilization review, case management, nurse review activities or coding experience preferred. Requires minimum three years previous validation experience or five plus years of coding and clinical documentation experience with extensive clinical knowledge in an acute hospital environment.
RN - Must be knowledgeable in:, (CD-10-CM/PCS -MS-DRGs, DRGs knowledge or use of InterQual criteria and clinical guidelines for admitting patients to the hospital.
Both RHIA and RN - Requires excellent and comprehensive knowledge of anatomy, physiology, as defined by the Medical Diagnostic Categories and all body systems. Strong background knowledge of disease process and pharmacology