FULLY REMOTE Registered Nurse - Experienced Clinical Documentation Integrity (CDI) Auditor

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 recent experience as a 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 of disease processes with direct experience in MS-DRG/APR-DRG, data analysis and reporting is required
• Proficienct in Microsoft Office required.
• Must have excellent leadership, problem-solving skills, and interpersonal and communication skills.
• Must have the ability to work independently.
• Computer literacy required as well as analytical and delegation skills. 

 
The Clinical Documentation Integrity Auditor will identify areas of improvement to reflect patient acuity fully, compliantly and accurately through DRG assignment, severity of illness, risk of mortality and risk adjustment factors via primarily in-depth, retrospective (post-discharge, pre-bill) audits 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 reviews, 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 multidisciplinary teams, providing feedback related to review findings for clinical documentation, clinical validation and query opportunities. The CDI Auditor will work closely with management to provide the status of reviews and propose topics for clinical documentation improvement opportunities/education needed. Other duties, as deemed necessary, which may include supporting and managing work outside of assigned unit or service line, as business needs or workload demands, collaborating with vendor partners or other projects that correlate with the 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. 
• Master's degree in nursing or related healthcare field preferred.

LICENSURE/CERTIFICATION: 

• Current licensure as a registered nurse in the state of New Jersey required. 
• CDIP/CCDS certification required or must be attained within one year of hire.  

EXPERIENCE: 

• 5 years of med-surg clinical experience required. Critical care experience preferred. 5 years of recent experience as a clinical documentation integrity (CDI) specialist RN required. CCDS or CDIP certification required or must be 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 and computer/Microsoft Office literacy required. 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 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.