UR/CDI Nurse Per Diem

Job Description
Position Summary
The Utilization Review (UR)/Clinical Documentation Integrity (CDI) nurse is part of a team that facilitates the quality, completeness, and accuracy of clinical documentation. Through extensive interaction with physicians, nursing staff, case managers related caregivers, and departments, to the UR/CDI Nurse ensures clinical documentation reflects clinical treatment, decisions, diagnoses and level of service rendered. The UR/CDI nurse serves as a resource for guidance and support to all members of the health care team on appropriate status, documentation guidelines, and assisting ongoing education and training related to improving clinical documentation.
Job Duties
Utilization Review:

• Perform admission, concurrent and retrospective medical reviews.
• Ensures effective and efficient payer communications to establish appropriate reimbursement for servcies.
• Functions as the liaison between various hospital departments, medical staff and payers on issues related to medical necessity for admission and continued stay.
• The UR/CDI nurse maintains open, transparent and clear lines of communication with physician advisors.
• Provides Utilization Management education to clinical staff as needed.
• Applies standardized criteria and guidelines to assist appropriate admission determinations and and patient class assignment (i.e. observation, inpatient and outpatient).
• Assist in monitoring resources while maintaining uncompromisingly high quality of care. Responsible for maintaining and ensuring the admission process remains fully compliant with Medicare and Medicaid regulations.
• Acts as a resource to the Care Management department regarding utilization, insurance and payer resolution matters.Identifies areas of opportunity regarding payment eligibility for clinical services and recommends corrective action.
• Participates in UR meetings.

Clinical Documentation Integrity:

• The Clinical Documentation Integrity Nurse is responsible for extensive record review and interaction with physicians, HIM coding professionals, nursing staff and other patient care givers to ensure accurate representation of patients conditions and severity of illness is captured in the patient's medical record
• Responsible for active participation in team meetings and development of clinical documentation guidelines, and education of staff on these guidelines, on an ongoing basis.
• Provides extensive and accurate reviews of medical records within specified timelines.
• Recognizes opportunities for documentation improvement to support severity of illness and quality of care, formulates clinically credible documentation clarifications/queries and follows up for responses as needed.
• Seeks clarification from physicians, nursing, and other staff in cases where documentation is absent, ambiguous, or contradictory.
• Provides provider education regarding query management within the electronic health record, and other CDI topics.
• Meets program quality and productivity guidelines and standards.
• Participates in Coding/CDI meetings.
• Collaborates with inpatient coders to determine appropriate Diagnosis Related Groups (MS-DRG, APR-DRGs, etc.) and ICD-10 code assignment.
• Collaborates with Coding and Quality Management teams to appropriately identify and develop compliant queries regarding Hospital Acquired Conditions (HAC) and Patient Safety Indicators (PSI).
• Meets revenue cycle goals, Key Performance Indicators (KPIs), quality and productivity standards.
• An experienced CDI nurse may assist in training and mentoring new CDI nurse to become acclimated to new environment, and understanding internal policies, procedures, standard work, and workflows.
• Abides by The Ethical Standards for Clinical Documentation Improvement (CDI). Professionals as set forth by the American Health Information Management Association.
• Participates in other assignments and special projects as assigned.

Education and Experience
Minimum Education and Experience Required
Minimum education (degree/type of degree). BSN
Minimum experience (minimum years type of experience). Minimum of 3 years of pediatric clinical experience required.
Preferred education experience. Previous UR/CDI, case management or care coordination preferred.
KSAs required upon hire or transfer (copy from KSA section below).
Licenses and Certifications
License and/or Certification
Required: RN
Preferred: CCDS, ACM
Knowledge, Skills, and Abilities
Knowledge of:

• Knowledge of Pathophysiology and Disease Process.
• Working knowledge of clinical information.
• High degree of familiarity with clinical care to establish credibility with physicians, LIPs, nurses and other members of the front-line care team.
• Must be able to provide clinical and financial education to colleagues, patients and families. Critical thinking, negotiation and the ability to set priorities are of highest importance.

Skilled at:

• Strong interpersonal and communication skills to manage competing priorities of the different stakeholders to ensure provision of high quality, high value and efficient care.
• Electronic medical record.

Ability to:

• Learn/develop the skills necessary to perform Clinical Documentation review of medical records.
• Understand and communicate the impact of CC/MCC's and other variables on the assignment of the various DRG methodologies.
• Handle multiple priorities and increasing responsibility.
• Collaborate with others to achieve a common goal through mutual cooperation.
• Influence others for positive and productive outcomes.
• Quickly process complex problems, identify key components, and develop plans for resolution.
• Learn and use multiple computer systems.