RN Clinical Document Integrity (CDI) Specialist

Minimum Education

BSN (Required)

Minimum Work Experience

5 years Experience with at least 3 years in clinical nursing. (Required)

Functional AccountabilitiesProfessional Practice/Research

• Participate in Shared Leadership.

• Contribute to the MAGNET Journey of Children’s National.

• Ensure that nursing practice is based on evidence of best practices.

• Accountable to participate in the Nursing Division’s Performance Improvement process (division or unit level).

• Participate in community activities.

Clinical Documentation

• Provide daily clinical evaluation of the medical record including physician and clinical documentation, lab results, diagnostic information, and treatment plans.

• Collaborate with Coder CDI Specialist in regard to interaction with physicians on documentation, and to resolve physician queries prior to patient discharge.

• Communicate with physicians (face-to-face or via clinical documentation inquiry forms) regarding missing, unclear, or conflicting medical record documentation; work with providers to ensure accurate and complete documentation is in the patient record.

• Apply nationally recognized criteria to support physician queries; address delays in closing of physician queries with the appropriate departmental and leadership individuals.

• Coordinate daily evaluation of documentation by the medical staff and/or healthcare team in accordance with Children’s National policies and procedures.

Program Activities

• Target activities to specific payers, DRGs, and teams based on financial and clinical data analysis.

• Collect and analyze data on program efforts and outcomes; identify patterns, trend variances, and opportunities to improve documentation review and process.

• Assist in the development and reporting of performance measures to the medical staff and/or healthcare teams; prepare physician specific data reports.

• Ability to follow-up on previous cases reviewed and prioritize work.

• Facilitate change process required to capture needed documentation such as template/forms design.

• Develop physician/provider education strategies to promote complete and accurate clinical documentation and correct negative trends.

Communicate

• Communicate verbally with physicians and/or healthcare team in a clear, timely, accurate, and professional manner.

• E-mail communication conveys clear, timely, accurate, and pertinent information in an organized professional format.

Performance Improvement

• Ensure all physician queries are in compliance with federal regulations.

• Identify opportunities for system-wide documentation improvement activities.

• Promote the development of accurate and complete clinical documentation with physicians and other members of the healthcare team.

• Active participation on departmental and/or hospital committees as assigned.

• Educate members of the patient care team regarding specific documentation needs; education team members about reporting and reimbursement issues identified through concurrent/ retrospective documents review and aggregate data analysis.

**Organizational AccountabilitiesOrganizational Accountabilities (Staff)
Organizational Commitment/Identification **

• Anticipate and responds to customer needs; follows up until needs are met

Teamwork/Communication

• Demonstrate collaborative and respectful behavior

• Partner with all team members to achieve goals

• Receptive to others’ ideas and opinions

Performance Improvement/Problem-solving

• Contribute to a positive work environment

• Demonstrate flexibility and willingness to change

• Identify opportunities to improve clinical and administrative processes

• Make appropriate decisions, using sound judgment

Cost Management/Financial Responsibility

• Use resources efficiently

• Search for less costly ways of doing things

Safety

• Speak up when team members appear to exhibit unsafe behavior or performance

• Continuously validate and verify information needed for decision making or documentation

• Stop in the face of uncertainty and takes time to resolve the situation

• Demonstrate accurate, clear and timely verbal and written communication

• Actively promote safety for patients, families, visitors and co-workers

• Attend carefully to important details - practicing Stop, Think, Act and Review in order to self-check behavior and performance