ED Clinical Documentation Integrity Specialist
The Emergency Department Clinical Documentation Integrity Specialist shall support a designated hospital within the North East Division and be based within the Emergency Department. The position shall support providers with clinical documentation integrity efforts and level of care decision support.
This includes adherence to Emergency Room documentation best practices such as capture of all clinically relevant aspects of the patient encounter including laboratory, radiologic, and other test results. Ensure the Emergency Room medical record accurately captures the process of evaluation, management, medical decision making, and medications, past history, disposition, and clinical assessment and/or diagnoses. Efforts shall include education on more specific or specified conditions versus those sign/symptom or unspecified conditions.
The position shall utilize criteria to confirm medical necessity for appropriate level of care settings. The Emergency Department Clinical Documentation Integrity Specialist shall provide education to providers on areas of documentation opportunities.
- Education: Associates or Bachelor’s degree required
- Experience: +2 years of Acute Care CDI experience;
- Certification/Licensure: Registered Nurse (RN) required
- Software/Hardware: Iodine and 3M experienced preferred
Other: Required to work at a designated hospital during peak admission times