Carle Looking for RN – Health Information Management – Clinical Documentation Integrity Specialist at Penfield, Illinois Full Time

Performs DRG assignment on select patients, as assigned to insure appropriate severity of illness and risk of mortality which impacts Case Mix Index and mortality ratings. Coordinates with physicians, nurses, ancillary staff, and the coders in Health Information Management to identify and record principal and secondary diagnoses, principal procedures, and assign the working DRG.

• Conducts the initial concurrent review process for all selected admissions
• Clarifies documentation in the medical record as appropriate through communication with the physicians, nurses, and ancillary staff
• Documents findings on the electronic DRG worksheet and identifies other key Pathway or quality indicators as appropriate
• Coordinates with the physicians, nurses, ancillary hospital staff, and Health Information Services Department’s coding staff to identify and record principal and secondary diagnoses, principal procedures, and assign the working DRG.
• Refers problematic cases to inpatient coding coordinator or supervisor/CDI and audit