RN CLINICAL DOCUMENT CASE MANAGER - CDI SPECIALIST (CLINICAL DOCUMENTATION INTEGRITY)

Monday - Friday 7 am - 3:30 pm, fully remote

Job Summary

The Clinical Documentation Case Managers are experienced nurses with clinical skills and knowledge in the application of documentation compliance necessary to support patient severity and corresponding organizational reimbursement. There is an expectation of a high level of understanding of the DRG reimbursement process and ICD-10 CM coding guidelines. The position is responsible for the improvement in overall quality, accuracy and completeness of clinical documentation, and assures all documentation describes each patient's clinical condition as accurately as possible and supports the level of service provided. The incumbent assists to facilitate the required level of detail in clinical documentation by educating and communicating extensively with the Medical Staff, other members of the health care team and Medical Records coding staff and demonstrates improvement in metrics such as CMI, Core Measure compliance, volume of Medical Record coding queries, etc.

Education

Minimum:

Graduate of a Registered Nurse Program

Preferred:

Bachelor Degree in Nursing

Registration/Certification/Licensure

:

Current PA RN license

Preferred: ACDIS credentialed, Certified Coding Specialist, RHIT, or RHIA

Experience

Minimum:

Three years of current medical/surgical/acute care nursing experience or two years of inpatient coding experience.

Preferred:

Documentation Compliance/Coding/DRG experience.

Other Requirements

:

N/A

Status

:

Non-Exempt

Physical Requirements:

The following frequency definitions apply to all Physical Requirements unless otherwise noted:

Occasional:

(0-1/3 of day , 0 - 2.5 hrs/day, 1 - 4 reps/hr)

Frequent:

(1/3 -2/3 of day , 2.5 - 5.5 hrs/day, 5 -24 reps/hr)

Constant

: (> 2/3rd of day , > 5.5 hrs/day, > 24 reps/hr)

xxxxx

NOTE: An asterisk (*) indicates that the item is an essential function.

Non-Material Handling

Standing*

• Remaining on ones feet in an upright position remaining stationary - FREQUENT

Walking*

• Remaining upright on ones feet, and moving about - FREQUENT

Sitting*

• Body remains in a seated position - FREQUENT

Stooping*

• To bend the body downward and forward by bending the spine at the waist - OCCASIONAL

Bending*

• To flex the upper body forward - OCCASIONAL

Twisting*

• To rotate the upper body forward - OCCASIONAL

Climbing*

• To move the body in any direction on equipment or structures that do not include stairs or ladders - N/A

Ladders*

• To ascend and descend ladders - N/A

Stairs*

• To ascend and descend stairs - FREQUENT

Kneeling*

• To move the body downwards and come to rest on both hands and both knees - OCCASIONAL

Squatting*

• To move the body downwards by bending both knees - OCCASIONAL

Crouching*

• To bend the body forward and downward by bending the spine and the legs - OCCASIONAL

Crawling*

• To move the body forward or backwards on hands and knees - N/A

Reaching Horizontal*

• To extend the arms and hands outward, remaining under shoulder height - OCCASIONAL

Reaching Overhead*

• To extend the arms and hands up and out over shoulder height - OCCASIONAL

Grasping*

• Using functional gripping of the hand to handle an object - CONSTANT

Finger Manipulation*

• To manipulate objects with the use of fingers - CONSTANT

Seeing*

• Using visual feedback to accomplish a task or activity - CONSTANT

Hearing*

• Using sound feedback to accomplish a task or activity - CONSTANT

Repetitive Upper Extremity Use*

• Using the arms and/or hands continuously or more than 2/3 of the total time - CONSTANT

Repetitive Lower Extremity Use*

• Using the legs and/or feet continuously or more than 2/3 of the total time - CONSTANT

Material Handling

Pushing*

• To exert a force upon an object in order to move it in a certain direction Pushing refers to moving an object away from theperson

CONSTANT

Up to 20#

Pulling*

• To exert a force upon an object in order to move it in a certain direction Pulling refers to moving an object towards the person

CONSTANT

Up to 20#

Lift*

• Floor to Waist

CONSTANT

Up to 20#

Lift*

• Waist to shoulder

CONSTANT

Up to 20#

Lift*

• Shoulder to overhead

CONSTANT

Up to 20#

Carrying*

• To transport an object or article using the arms or hands (> 10 feet)

CONSTANT

Up to 20#

Environmental Factors

Working alone

• OCCASIONAL

Working in cramped quarters

• FREQUENT

Constant interruptions

• CONSTANT

Working with hands in water

• N/A

Use of power tools

• N/A

Working on ladders/scaffolding

• N/A

Exposure to vibration

• N/A

Exposure to dust

• N/A

Exposure to noise (constant)

• N/A

Exposure to electrical energy (outlets, etc)

• N/A

Exposure to temperature changes (heat, cold, humidity), that require special clothing

• N/A

Exposure to slippery walking surfaces

• N/A

Exposure to solvents, grease, oils

• N/A

Exposure to radiant energy, ie computer terminal (more than 4 hours per shift)

• CONSTANT

Working with bloodborne pathogens

• N/A

Cardiovascular Energy Requirements - Physical Demand

PhysicalDemand

MetLevel

Examples of similar activity intensity

Sedentary toLight

0 - 3.5

Light house cleaning, washing dishes, serving food, food shopping, sitting, standing, computer work.

Medium

3.6 - 6.3

House work (mopping, scrubbing), health club exercising, treadmill work, stretching, yoga, walk/run-playwith children, aerobic class, dancing, carrying bucket/wood, auto body repair, shoveling snow, golf(carrying clubs).

Heavy to VeryHeavy

> 6.4

Calisthenics (push up, pull up, sit up, vigorous effort), carrying groceries upstairs, shoveling coal, bailinghay, fire fighting, sawing by hand, splitting wood.

As relates to this position:

Sedentary to Light - CONSTANT

Medium - N/A

Heavy to Very Heavy - N/A

I. Specific Job Responsibilities