Description

The CDI Quality Review Nurse (QRN) will work under the direction of the Clinical Documentation Integrity (“CDI”) Manager and conduct second-level reviews of targeted cases to identify and capture opportunities to improve the integrity of the medical record. The focus of the Quality Review Nurse will be on identifying and capturing methodology-specific risk variables (Vizient, HCC’s, Elixhauser) on a post-discharge, pre-coding/billing basis, as well as identifying potential process improvements to capture the opportunities concurrently. The Quality Review Nurse will also validate that the record reflects the most appropriate principal diagnosis and diagnosis related group (DRG). The Quality Review Nurse will support the objective for accurate reflection of patient acuity, severity of illness, risk of mortality, and DRG assignment in compliance with industry rules and regulations.   

ESSENTIAL FUNCTIONS
Conduct post-discharge, pre-coding/billing reviews on targeted records identified for second-level review for opportunity to accurately capture methodology-specific risk variables (Vizient, HCC’s, Elixhauser); present on admission (POA) status, patient admission source, avoidable patient safety indicators (PSI’s), and DRG assignment in compliance with industry rules and regulations
        If a documentation opportunity is identified, place physician query and follow up for response

        If coding opportunity is identified, coordinate with Coding Team to review and address opportunity, as applicable

Utilize methodology-specific risk calculators and guidance documents to understand if additional diagnoses and/or risk variables will impact the reported quality impact of a specific patient encounter
Maintain a summary of opportunities identified through second-level review for feedback and education with the CDS Team, Providers, and Coding Team
Identify and communicate any process improvement opportunities for front-end correction and education
Periodically review the criteria established for cases triggering a second-level review and recommend updates or modifications to the criteria to maximize impact on quality scores
Maintains an expert level of knowledge of CDI and Coding related guidelines and practices
Other duties as assigned
 

Requirements

MINIMUM QUALIFICATIONS

Education/Experience

Registered Nurse (RN) with extensive clinical background
Bachelor’s degree in nursing or Master’s degree in nursing preferred
Minimum of 5 years, preferred 7+ years; patient care nursing experience in acute care setting
Preferred in critical care
Minimum of 3 years, preferred 5+ years CDI experience 
Certified Clinical Documentation Specialist (CCDS) issued by the Association of Clinical Documentation Improvement Specialists (ACDIS) or Certified Documentation Improvement Practitioner (CDIP) issued by The American Health Information Management Association (AHIMA)
Extensive clinical knowledge and understanding of pathology/physiology
Strong critical thinking skills and the ability to review the medical record to identify information not yet documented but supported by clinical indicators or clinical clues
Knowledge of age-specific needs and the elements of disease processes and related procedures
Excellent written and verbal communication skills; ability to concisely and effectively communicate with Providers, Leadership, etc. 
Assertive personality traits to facilitate ongoing physician communication
Working knowledge of inpatient admission criteria
Ability to work independently in a time-oriented environment
        Experience working in a remote environment preferred