Since 1887, Crouse Health has been a leading healthcare provider in Central New York. We’ve combined a family-friendly culture with a passion to provide the best care, which creates an environment where both patients and team members feel valued. Crouse Health offers a full range of general and specialty care, inpatient and outpatient services, as well as community health education and outreach programs.

Crouse Health is hiring a Clinical Documentation Improvement (CDI) Registered Nurse (RN).

Schedule: Per Diem, 7:00am-3:30pm

Pay Range: $44.28/hour

CDI RN Position Responsibilities:

• Provides professional judgment and knowledge of roles as it pertains to the Crouse Hospital Professional Nursing Practice Model.
• Carries out duties and responsibilities per legal requirements under the Registered Nurse Scope of Practice, with emphasis on leading a culture of safe care.
• Delegates and coordinates appropriate tasks to other staff while maintaining accountability for actions delegated. Delegated tasks will be clearly communicated and inclusive of verification of completion.
• Serves as an advocate for patients and families while applying ethical principles of care.
• Consults patient data to identify trends in patient status; applies findings to enhance plan of care.
• Monitors and evaluates patient responses to treatment/plan of care during hospital stay.
• Gives an accurate, objective and complete hand off communication with change of caregivers.
• Utilizes and engages in evidence-based practice to deliver quality patient care.
• Demonstrates characteristics and skills that promote critical thinking in clinical problem-solving situations.
• Assumes other duties as assigned by department leadership.
• Routinely reviews records to identify opportunities for intervention and facilitate an accurate representation of severity of illness.
• Professionally educates medical staff and other healthcare providers on regulatory coding guidelines through open communication and in-services.
• Proactively initiates and accurately maintains records of interventions and follows through on recommendations to ensure consistency and documentation improvement.
• Actively participates in retrospective medical record reviews to collect data and/or resolve coding discrepancies.
• Properly establishes measurable benchmarks and constantly monitors practices and processes to ensure program compliance.
• Actively serves as a member of the clinical documentation improvement team. May occasionally be required to facilitate meetings and provide benchmark data detailing successes and opportunities.
• Consistently maintains the highest level of confidentiality with all departmental and organizational information and data.

CDI RN Position Requirements:

• Graduate from an accredited nursing degree program required.
• Bachelor of Science degree in Nursing preferred. Certification in a specialty area.
  • Bachelor’s Degree required within 8 years of being hired for those licensed after 2017.
• Currently licensed as a Registered Professional Nurse in New York State or, if hired as a Graduate Nurse, a NYS limited licensure work permit must be obtained within ninety (90) days of graduation and the GN must successfully pass the NCLEX exam within 120 days of the beginning of employment to obtain the required professional nursing licensure with New York State.
• Basic Life Support (BLS) certification required.
• Advanced Cardiac Life Support (ACLS) and/or Pediatric Advanced Life Support (PALS) certification must be obtained within one (1) year of the hire date, if deemed necessary for the position based on the scope of the assigned role.
• Must have the ability to pass clinical competency test with a score of 70 or above. Test will be administered by Human Resources.
• Five (5) years of inpatient coding, Case management or active nursing experience (especially critical care) required.
• Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Integrity Practitioner (CDIP) certification preferred.