Essential Functions

• Facilitates clinical documentation improvement activities to ensure accurate representation of patient acuity, severity of illness, risk of mortality, and quality outcomes.
• Reviews concurrent medical records for completeness, accuracy, compliance, and documentation opportunities.
• Identifies opportunities for documentation improvement through analysis of clinical indicators, medical necessity, and patient care documentation.
• Develops and communicates clinically supported documentation clarifications to physicians, advanced practice providers, and other members of the healthcare team.
• Initiates and formulates CDI severity worksheets and documentation queries that support compliant documentation practices.
• Reviews and reconciles documentation related to severity of illness (SOI), risk of mortality (ROM), patient safety indicators (PSI), hospital-acquired conditions (HAC), hierarchical condition categories (HCC), and other quality measures.
• Accurately enters and maintains CDI data within designated software systems, supporting reporting and performance metrics.
• Collaborates with physicians, nursing staff, HIM professionals, coders, and other healthcare team members to improve documentation quality and accuracy.
• Works with Health Information Management staff to resolve DRG assignment discrepancies and coding-related documentation issues.
• Conducts timely follow-up reviews on concurrent cases and prioritizes cases requiring clarification resolution.
• Educates physicians, advanced practice providers, nursing staff, and other healthcare professionals regarding documentation requirements, regulatory guidelines, and best practices.
• Maintains physician engagement and supports timely responses to documentation clarification requests.
• Participates in departmental meetings, educational initiatives, performance improvement activities, and process improvement efforts.
• Assists with orientation, training, mentoring, and precepting of new team members.
• Completes annual educational projects and presentations for the CDI team.
• Maintains documentation integrity and compliance with organizational, regulatory, and accreditation requirements.
• Performs other duties as assigned.

Knowledge, Skills, and Abilities

• Excellent verbal and written communication skills with the ability to develop and maintain effective professional relationships.
• Demonstrated ability to communicate effectively with physicians, advanced practice providers, and interdisciplinary healthcare teams.
• Strong organizational, prioritization, and time management skills.
• Ability to manage multiple responsibilities and competing priorities in a fast-paced healthcare environment.
• Proficiency in computer applications, electronic health record systems, CDI software, and related technologies.
• Ability to work effectively with multiple software applications simultaneously.
• Strong critical thinking, clinical reasoning, problem-solving, and decision-making skills.
• Ability to analyze clinical documentation and identify opportunities for improvement.
• Knowledge of pathophysiology, disease processes, clinical treatment modalities, and patient care practices.
• Knowledge of clinical documentation improvement principles and documentation requirements.
• Knowledge of coding concepts, DRG methodology, reimbursement systems, and healthcare quality measures.
• Knowledge of regulatory, compliance, accreditation, and quality reporting requirements.
• Ability to organize, interpret, and present information clearly and concisely.
• Demonstrated ability to learn, develop, and refine clinical documentation improvement skills.
• Dependable, self-motivated, professional, and collaborative.
• Ability to work independently while maintaining strong teamwork and customer service standards.

Education

• RN/Associate's Degree required.
• BSN Preferred

Field of Study

• Nursing or a health-related field.

Work Experience

• 5 years of Clinical Documentation Integrity (CDI) experience involving Obstetric and/or Neonatal Intensive Care Unit (NICU) patient populations, including review of Obstetric and NICU cases.
• Acute care nursing experience in Obstetrics, Labor & Delivery, Mother-Baby, Women's Services, NICU, or related specialties strongly preferred.
• Five years of Clinical Documentation Improvement (CDI) experience required.

Required Education

• Current and active Registered Nurse (RN)
• Certified Clinical Documentation Specialist (CCDS) required.
• JATA training preferred.

Schedule: Full time Shift: Day (United States of America) Address: 9100 W 74TH ST City: SHAWNEE MISSION State: Kansas Postal Code: 66204

Pay Range: $67,662.40 - $125,860.80