Registered Nurse - Clinical Documentation Integrity Auditor - Full Time

Minimum Qualifications:

• Graduate of an accredited school of nursing required.
• Current licensure as a registered nurse in the state of New Jersey required.
• 5 years of recent experience clinical documentation integrity/improvement specialist RN required.
• 5 years of med/surg clinical experience required. Critical care experience preferred. Master's degree in nursing or related healthcare field preferred.
• CCDS or CDIP certification required (or attained within one year of hire).
• Excellent clinical knowledge and disease processes with direct experience with MS-DRG/APR-DRG, data analysis and reporting are required.
• Proficiency in Microsoft Office required.
• Excellent leadership, problem-solving, interpersonal, written communication, analytical and delegation skills required, as well as the ability to work independently and computer literacy.

POSITION SUMMARY
The clinical documentation integrity auditor will identify areas of improvement to fully, compliantly and accurately reflect patient acuity through DRG assignment, severity of illness, risk of mortality and risk adjustment factors via primarily in-depth retrospective (post-discharge, prebill) audit of the patient's clinical record and related findings and queries performed by the CDI RN specialist. The CDI audit may also perform post-bill reviews from referrals from internal organizational departments/initiatives, external review, physician service lines or other various sources.

The CDI auditor will analyze the audit results and use data, spreadsheets and dashboards to identify areas of opportunity. The CDI auditor will review results with the CDI manager, making recommendations for developing educational and process improvement plans to achieve departmental objectives and goals. The focus of these audits will be related to overall team effectiveness and individual performance. The CDI auditor is considered to be a subject matter expert regarding basic and intermediate CDI and coding concepts. The CDI auditor works collaboratively with and provides feedback related to review findings for clinical documentation, clinical validation and query opportunities to multidisciplinary teams. The CDI auditor will work closely with management to provide the status of reviews and propose topics for and clinical documentation improvement opportunity/education needed. Other duties as deemed necessary may include support and management of work outside of assigned unit or service line as business or workload demands and/or collaborating with vendor partners or other projects that correlate with growth/scope of the department.

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

QUALIFICATIONS

• EDUCATION: Graduate of an accredited school of nursing required. Bachelor's in nursing preferred.
• LICENSE/CERTIFICATION: Current licensure as a registered nurse in the state of New Jersey required. CDIP/CCDS certification required or attainment within one year of hire. Master's degree in nursing or related healthcare field preferred.
• EXPERIENCE: 5 years of med/surg clinical experience required; critical care experience preferred. 5 years of recent experience as Clinical Documentation Integrity (CDI) specialist RN required. CCDS or CDIP certification required (or attained within one year of hire). Requires in-depth understanding of concepts, practices and procedures applicable to CDI and coding, as well as advancing knowledge in quality outcomes and the impact of CDI/coding initiatives and data analysis. Ability to work independently and use good judgment in decision making. Excellent leadership, interpersonal and written communication skills; computer/Microsoft Office literacy; and analytical and delegation skills required. 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.

Remote-eligible.

REPORTING RELATIONSHIP
This position report to department leadership and may supervise incumbents as assigned.

The above statement reflects the general details considered necessary to describe the principal 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.