CDI Specialist, RN (2018)

This position is responsible for improving the overall quality and completeness of clinical documentation for inpatient admissions, Same Day Surgery, Observation and Emergency Trauma Center encounters. This position facilitates concurrent modifications to clinical documentation through extensive interaction with physicians and other providers, Clinical Excellence and Patient Safety (CEPS), nursing staff, other patient care givers and HIM coding staff to ensure clinical severity and services rendered to patients are accurately reflected in the documentation. This requires review of appropriate diagnosis, procedures and working DRG's/APC's based on clinical indicators to assure appropriate clinical severity is captured. This position also ensures the accuracy and completeness of clinical information used for measuring and reporting physician data and Trinity Health outcomes. Educates members of the patient care team on documentation related issues on an ongoing basis. The Clinical Documentation Specialist reports to the Enterprise Director of HIM/CDI.