RN - Clinical Documentation Integrity Quality & Safety Specialist - Day Shift

RN – Clinical Documentation Integrity Quality & Safety Specialist

Day Shift (Hours: M-F 8 hours) Hybrid / No Weekends or Holidays!

Newark, DE

Christiana Care Hospital is hiring a Registered Nurse (RN) Clinical Documentation Integrity Quality & Safety Specialist to focus on Quality and Safety while providing leadership and support for systemwide best practice documentation and coding that are consistent with the organizational mission, priority, and goals. 

This include ensuring that documentation and coding captures the complete clinical picture, and that safety and quality data is reported completely and accurately. This is done via chart review, provider queries, consulting with Physician Advisors and working closely with Coding management to ensure all quality and safety inclusion and exclusions are accurately captured in documentation, and coding. Resulting in accurate data to benchmark CCHS with other like health systems to support appropriate reimbursement and clinical severity for our patients.

SCOPE, PURPOSE, AND FREQUENCY OF CONTACTS:

Interacts regularly with physician and physician advisor leaders, organizational management, Performance Improvement, Data Analytics, CDI staff, HIM/coding staff.

Principle Duties & Responsibilities:

• Participates in performance improvement activities regarding documentation/coding improvement.

• Reviews targeted (quality, safety, length of stay, etc.) encounters for completeness and accuracy.  Collaborates w/Physician Advisors, as needed.

• Uses Vizient tools/data to identify documentation opportunities and targeted physician education to achieve department goals.

• Manage, coach, and/or mentor less experienced health care personnel in best practice documentation specifically those associated with Quality and Safety, Length of Stay, Etc.

• Ensures all concurrent and retrospective queries are clinically relevant and escalates to Physician Champions, as appropriate.

• Facilitates DRG Reconciliation and provides feedback to CDS/Coding and Leadership.

• Actively participates in systemwide management activities, attend meetings and in-service/educational programs and other activities as requested.

Education & Experience Requirements:

• Bachelor’s degree in nursing

• Delaware RN License or compact Nursing License.

• Strong medical terminology & clinical awareness

• Effective communication and clinical skills

• Clinical Documentation Certification (CCDS) required within 1 year of eligibility.

• Minimum of 3 years CDI experience. Focus on PSIs preferred.

• Minimum of 3 years recent experience as a Registered Nurse in an inpatient acute care hospital setting preferred.

PHYSICAL DEMANDS:

Ability to ambulate within the hospital setting (walking, stairs, etc.). Occasional sitting, standing and lifting loads of 5-10 pounds. Ability to utilize computer equipment/programs. Ability to sit or stand at a computer workstation and proficiently utilize computer equipment/programs for long periods of time.

• Prolonged daily review of charts on computer screen
• Sitting for extended periods of time

WORKING CONDITIONS:

• Limited patient contact
• Normal Office Environment
• Possible remote work opportunities