FREE ACCESS
5,000–10,000 jobs/day
See all jobs on Scoutfield
Search thousands of fresh jobs every day.
Discover
- Fresh listings
- Fast filters
- No subscription required
Create a free account and start exploring right away.
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 accuracy, and regulatory compliance, with a strong focus on enhancing medical record documentation and supporting quality outcomes. Proficient in physician education regarding documentation requirements and reimbursement policies.
Highest-signal resume keywords
Clinical Documentation Improvement (CDI)Active US RN LicenseElectronic Medical Records (EMR)Coding Guidelines KnowledgeClinical Experience in ICU
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Medical Record ReviewDocumentation EvaluationDRG AssignmentCoding AccuracyMortality ReviewPSI ReviewPhysician Query ProcessQuality Improvement InitiativesClinical Documentation StandardsReimbursement Policies
Soft Skills
CollaborationEducationCommunication
Tools & Technologies
CDI PlatformsEMR Platforms
Certifications & Qualifications
Associate’s Degree in NursingBachelor’s Degree in Nursing (Preferred)
Industry Keywords
CMS Rules and RegulationsFederal Coding GuidelinesState Coding GuidelinesCoding Clinic GuidelinesAcute Care Hospital
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 documentation
- Conduct mortality reviews, PSI reviews, and other focused reviews identified by CDI leadership
- Facilitate and obtain appropriate physician documentation supporting severity of illness, expected risk of mortality, and complexity of care
- Initiate physician interaction through the physician query process and/or participation in physician rounding
- Educate physicians and other staff on documentation requirements, coding guidelines, and reimbursement policies
- Assign working DRGs and review patient records throughout hospitalization to ensure codes are reported at the highest specificity
- Collaborate with coders, auditors, quality improvement teams, and other stakeholders to resolve documentation issues and improve coding accuracy
- Participate in documentation improvement initiatives and formal and informal education plans for providers and the CDI team
- Stay updated 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
- An active US RN license is required
- Front line CDI experience in an acute care hospital
- Three to five years of recent clinical work experience in the medical-surgical area, ICU, telemetry, and/or emergency department
- Knowledge or experience in electronic medical records (EMR) platforms and CDI platforms
- Highly skilled in CDI practices, coding, and documentation requirements related to quality outcomes, medical record data accuracy, and reimbursement
- Ability to stay abreast of CMS rules and regulations
- Clinical experience in ICU, medical-surgical, telemetry, or ED
- Knowledge of hospital coding code sets, policies and procedures, 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, think boldly, and create meaningful work
- Reasonable accommodation support during the application process