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Registered Nurse, CDI
Tenet Healthcare. Review patient medical records within 24–48 hours of admission to evaluate documentation, assign principal and secondary diagnoses and procedures, and support accurate MS-DRG assignment, risk of mortality, and severity of illness .
Core Competencies
Role fitCore Competencies
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Demonstrates expertise in Clinical Documentation Integrity (CDI) through accurate evaluation of patient medical records, effective communication with healthcare providers, and adherence to coding compliance standards. Proficient in MS-DRG classification, ICD-10-CM and PCS coding, and critical thinking to resolve documentation queries.
Highest-signal resume keywords
Clinical Documentation Integrity (CDI)MS-DRG ClassificationICD-10-CM and PCS CodingRegistered Nurse LicenseEffective Communication Skills
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
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Hard Skills
Disease Pathophysiology KnowledgeCoding Compliance KnowledgeCritical ThinkingProblem SolvingDeductive ReasoningFormulating Clinically Compliant QueriesAuditing and CDI Program MonitoringIntermediate MS-Word SkillsIntermediate MS-Excel Skills
Soft Skills
Effective Written CommunicationEffective Verbal CommunicationAbility to Work Independently
Certifications & Qualifications
CDIPCCDS
Industry Keywords
Acute Care NursingMedical/Surgical NursingIntensive Care NursingCase ReviewUtilization ReviewProvider ExperienceAHA Coding GuidelinesCMS Directives
About the role
Key responsibilities & impact- Review patient medical records within 24–48 hours of admission to evaluate documentation, assign principal and secondary diagnoses and procedures, and support accurate MS-DRG assignment, risk of mortality, and severity of illness
- Conduct follow-up patient reviews every 24–48 hours or as needed through discharge
- Formulate physician queries for missing, unclear, or conflicting documentation
- Collaborate with providers, case managers, nursing staff, and ancillary staff to resolve queries before discharge
- Complete Clinical Documentation Integrity activities and coding issue follow-up
- Assist with provider education, rounding, and open-query resolution
- Stay current with AHA Official Coding and Reporting Guidelines, CMS directives, and ICD-10-CM and PCS coding
- Attend CDI boot camps, coding training, education lectures, and assigned learning modules
- Assist in training department staff new to CDI
- Perform other duties as assigned
Requirements
What you’ll need- Zero (0) to two (2) years CDI experience
- Two (2) plus years’ nursing experience in Medical/Surgical/Intensive Care and/or Case/Utilization Review
- Two (2) plus years’ Provider experience in Medical/Surgical/Intensive Care and/or Case/Utilization Review
- Graduate from a Nursing program, BSN, or graduate program; OR graduate from Medical Doctor and/or Foreign Medical Doctor Program
- Active state Registered Nurse license; OR Graduate MD and/or FMD license
- Proficient knowledge of disease pathophysiology and drug utilization
- Intermediate knowledge of MS-DRG classification and reimbursement structures
- Knowledge of coding compliance and regulatory standards
- Ability to apply coding conventions, official guidelines, and Coding Clinic advice to health record documentation
- Critical thinking, problem solving and deductive reasoning skills
- Effective written and verbal communication skills
- Excellent computer skills including MS Word/Excel
- Ability to formulate clinically compliant, credible queries
- Ability to comply with robust auditing and CDI program monitoring
- Ability to work independently in facility on-site and virtual office settings
- Must be able to travel as needed, not to exceed 10%
- Regular and reliable attendance
- Preferred: Acute Care nursing and/or Provider relevant experience
- Preferred: CDIP or CCDS
Benefits
Comp & perks- Competitive benefits package
- Resources and incentives to support career advancement
- Required vaccinations and screenings obtained and confirmed prior to employment, as applicable and permitted by law