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Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in Clinical Documentation Improvement (CDI) practices, coding requirements, and regulatory compliance, with a strong focus on enhancing medical record quality and supporting reimbursement processes. Proficient in collaborating with healthcare teams to facilitate accurate documentation and improve patient care outcomes.
Highest-signal resume keywords
Clinical Documentation Improvement (CDI)Active US RN LicenseElectronic Medical Records (EMR)Coding GuidelinesCMS Rules and Regulations
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Clinical Documentation Improvement (CDI) PracticesMedical Record ReviewMortality ReviewsDRG AssignmentCoding SpecificityDocumentation Quality EvaluationPhysician EducationQuery Process FacilitationQuality Improvement InitiativesClinical Experience in ICU
Soft Skills
CollaborationCommunicationEducationInterpersonal SkillsProblem-Solving
Tools & Technologies
CDI PlatformsElectronic Medical Records (EMR)
Certifications & Qualifications
Associate’s Degree in NursingBachelor’s Degree in Nursing (Preferred)
Industry Keywords
Acute Care HospitalFederal Coding GuidelinesState Coding GuidelinesReimbursement PoliciesQuality Outcomes
About the role
Key responsibilities & impact- Conduct clinically based concurrent and retrospective reviews of inpatient medical records
- Evaluate clinical-service documentation and identify opportunities to improve medical record quality
- Conduct mortality reviews, PSI reviews, and other focused reviews identified by CDI leadership
- Facilitate and obtain physician documentation supporting severity of illness, expected risk of mortality, and complexity of care
- Initiate physician interaction through the query process and/or participation in physician rounding
- Educate physicians and staff on documentation requirements, coding guidelines, and reimbursement policies
- Assign working DRGs and review patient records throughout hospitalization for coding specificity
- Collaborate with coders, auditors, quality improvement teams, and other stakeholders to resolve documentation issues
- Participate in documentation improvement initiatives and formal and informal education plans
- Stay current on clinical documentation standards, coding rules, and regulatory requirements
Requirements
What you’ll need- Associate’s Degree in Nursing required; Bachelor’s Degree in Nursing preferred
- Active US RN license required
- Front line CDI experience in an acute care hospital
- Three to five years of recent clinical work experience in medical-surgical, ICU, telemetry, and/or emergency department settings
- Knowledge or experience with electronic medical records (EMR) platforms and CDI platforms
- Highly skilled in CDI practices, coding, and documentation requirements related to quality outcomes and reimbursement
- Knowledge of CMS rules and regulations
- Clinical experience in ICU, medical-surgical, telemetry, or emergency department
- Ability to work with Hospital coding code set, Federal and State coding reimbursement guidelines, and Coding Clinic Guidelines
Benefits
Comp & perks- Annual bonus plan at a target of 5.00%
- Competitive benefits package
- Opportunities to learn, collaborate across groups, and explore new career paths
- Opportunity to contribute meaningful work and give back to the community