RN - Clinical Document Integrity Specialist

apartment Carle Health location_onChampaign, IL, US

$34.31 - $59.01 / hour

Overview

Performs inpatient chart review to determine appropriate DRG assignment and assures appropriate documentation in the chart to support clinical care provided, including 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. Performs second level review of specific DRGs as assigned. Presents education related to CDI topics to peers and providers we needed or requested. Reviews DRG denials and provides information to the denials team related to appealing the encounter

Qualifications

CDI EXPERIENCE REQUIRED

Certifications: Registered Health Information Administrator (RHIA) - American Health Information Management Association (AHIMA)American Health Information Management Association (AHIMA); Licensed Registered Professional Nurse (RN) - Illinois Department of Financial and Professional Regulation (IDFPR)Illinois Department of Financial and Professional Regulation (IDFPR), Education: Associate's Degree: Related Field, Work Experience: CDI; Clinical bedside

Responsibilities

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. Assures documentation in chart represents a true clinical picture of the patient diagnoses and supports care that was given and DRG assigned.Documents findings within Carle CDI software and updates software as required to reflect status of the encounter and any follow up.Coordinates with the physicians, nurses, ancillary hospital staff, and Health Information Management Department's coding staff to identify and record principal and secondary diagnoses, principal procedures, and assign the working DRG.Follows query process and escalates as necessary.Conducts education related to CDI topics to peers and providers as needed or requested.Performs second level review on selected inpatient encounters.Reviews denials for accurate and complete documentation and develops appeal letter when needed.Attends mandatory and regular education sessions as needed. Follows appropriate workflow in EPIC and CDI software and notifies one up leader of any issues. May serve as an "expert" and participate in testing for upgrades as needed.

About Us

Find it here.

Discover the job, the career, the purpose you were meant for. The supportive and inclusive team where you can thrive. The place where growth meets balance - and opportunities meet flexibility. Find it all at Carle Health.

Based in Urbana, IL, Carle Health is a healthcare system with nearly 16,600 team members in its eight hospitals, physician groups and a variety of healthcare businesses. Carle BroMenn Medical Center, Carle Foundation Hospital, Carle Health Methodist Hospital, Carle Health Proctor Hospital, Carle Health Pekin Hospital, and Carle Hoopeston Regional Health Center hold Magnet® designations, the nation’s highest honor for nursing care. The system includes Methodist College and Carle Illinois College of Medicine, the world’s first engineering-based medical school, and Health Alliance™. We offer opportunities in several communities throughout central Illinois with potential for growth and life-long careers at Carle Health.

We are an Equal Opportunity Employer and do not discriminate against any employee or applicant for employment because of race, color, sex, age, national origin, religion, sexual orientation, gender identity, status as a veteran, and basis of disability or any other federal, state or local protected class. Carle Health participates in E-Verify and may provide the Social Security Administration and, if necessary, the Department of Homeland Security with information from each new employee's Form I-9 to confirm work authorization. | For more information: human.resources@carle.com.

Compensation And Benefits

The compensation range for this position is $34.31per hour - $59.01per hour. This represents a good faith minimum and maximum range for the role at the time of posting by Carle Health. The actual compensation offered a candidate will be dependent on a variety of factors including, but not limited to, the candidate’s experience, qualifications, location, training, licenses, shifts worked and compensation model. Carle Health offers a comprehensive benefits package for team members and providers. To learn more visit careers.carlehealth.org/benefits.

Share this job

Related Jobs

Full-time

Registered Nurse (RN)

apartment Accolade Healthcare of Paxton on Pells location_onPaxton, IL

About Us At Accolade Healthcare, we put an emphasis on the satisfaction of our team members, understanding that a foundation built on quality patient care starts with the people providing the care. Our goal is to care for our staff with respect, empathy, and appreciation. Providing our professional staff with safe and efficient equipment to complete their mission is our priority. Accolade is committed to never being satisfied with industry norms and standards – instead, always searching for creative methods to equip our team with the tools necessary to achieve success. Job Summary As a Registered Nurse (RN) , you will play a critical role in promoting and restoring patients' health by completing the nursing process. You will collaborate with physicians and multidisciplinary team members, provide physical and psychological support to patients and their families, and supervise assigned team members. A Registered Nurse (RN) ensures the delivery of high-quality care and fosters a compassionate environment for everyone in the healthcare setting. Benefits Benefits: Medical, Dental, Vision and additional other voluntary benefits 401k with company match Generous Paid Leave Policy Free uniforms after hire Daily Pay partner Newly renovated breakrooms - fully stocked beverages Monthly Employee Appreciation Events and Celebrations Duties and Responsibilities As a Registered Nurse (RN) , your responsibilities include: Identifying patient care requirements by establishing personal rapport with patients and their support systems. Establishing a compassionate environment by providing emotional, psychological, and spiritual support to patients and families. Promoting patient independence by: Establishing patient care goals. Teaching patients and families about conditions, medications, and self-care skills. Addressing questions and concerns. Ensuring quality of care by: Adhering to therapeutic standards. Measuring health outcomes against patient care goals and standards. Making or recommending necessary adjustments. Following hospital and nursing division's philosophies and standards of care. Resolving patient problems and needs using multidisciplinary team strategies. Maintaining a safe and clean working environment by: Complying with procedures, rules, and regulations. Calling for assistance from healthcare support personnel as needed. Protecting patients and employees by adhering to infection control policies, medication administration protocols, and controlled substance regulations. Qualifications and Skills To excel as a Registered Nurse (RN) , you will need: Required Qualifications : Associate Degree in Nursing (ADN) or Bachelor’s Degree in Nursing (BSN). Active Registered Nurse (RN) license in good standing with the Illinois Department of Financial and Professional Registry. Skills : Clinical skills, bedside manner, and infection control expertise. Proficiency in administering medication and maintaining health promotion and maintenance. Strong teamwork, multitasking, listening, and verbal communication skills. Physiological knowledge and ability to implement medical teamwork strategies effectively.

Full-time

Registered Nurse (RN)

apartment Accolade Healthcare of Paxton Senior Living location_onPaxton, IL

About Us At Accolade Healthcare, we put an emphasis on the satisfaction of our team members, understanding that a foundation built on quality patient care starts with the people providing the care. Our goal is to care for our staff with respect, empathy, and appreciation. Providing our professional staff with safe and efficient equipment to complete their mission is our priority. Accolade is committed to never being satisfied with industry norms and standards – instead, always searching for creative methods to equip our team with the tools necessary to achieve success. Job Summary As a Registered Nurse (RN) , you will play a critical role in promoting and restoring patients' health by completing the nursing process. You will collaborate with physicians and multidisciplinary team members, provide physical and psychological support to patients and their families, and supervise assigned team members. A Registered Nurse (RN) ensures the delivery of high-quality care and fosters a compassionate environment for everyone in the healthcare setting. Benefits Benefits: Medical, Dental, Vision and additional other voluntary benefits 401k with company match Generous Paid Leave Policy Free uniforms after hire Daily Pay partner Newly renovated breakrooms - fully stocked beverages Monthly Employee Appreciation Events and Celebrations Duties and Responsibilities As a Registered Nurse (RN) , your responsibilities include: Identifying patient care requirements by establishing personal rapport with patients and their support systems. Establishing a compassionate environment by providing emotional, psychological, and spiritual support to patients and families. Promoting patient independence by: Establishing patient care goals. Teaching patients and families about conditions, medications, and self-care skills. Addressing questions and concerns. Ensuring quality of care by: Adhering to therapeutic standards. Measuring health outcomes against patient care goals and standards. Making or recommending necessary adjustments. Following hospital and nursing division's philosophies and standards of care. Resolving patient problems and needs using multidisciplinary team strategies. Maintaining a safe and clean working environment by: Complying with procedures, rules, and regulations. Calling for assistance from healthcare support personnel as needed. Protecting patients and employees by adhering to infection control policies, medication administration protocols, and controlled substance regulations. Other duties as assigned. Qualifications and Skills To excel as a Registered Nurse (RN) , you will need: Required Qualifications : Associate Degree in Nursing (ADN) or Bachelor’s Degree in Nursing (BSN). Active Registered Nurse (RN) license in good standing with the Illinois Department of Financial and Professional Registry. Skills : Clinical skills, bedside manner, and infection control expertise. Proficiency in administering medication and maintaining health promotion and maintenance. Strong teamwork, multitasking, listening, and verbal communication skills. Physiological knowledge and ability to implement medical teamwork strategies effectively.

Outpatient

Full-time

RN Practice Management-Tuscola Clinic Cardiology/Internal Med

apartment Sarah Bush Lincoln location_onTuscola, IL

$29.08 - $45.07 / hour

Internal Employees: Please ensure that you are logged into Workday and applying through the Jobs Hub before proceeding. RN Practice Management-Tuscola Clinic Cardiology/Internal Med Job Description RN-Practice Management is responsible for providing assistance to providers in the direct and indirect care of Practice Management patients. Performs patient or office related duties including but not limited to clinical measurements and data collection. Documents data and provider directed information clearly and accurately in patient records. Functions clinically as support staff to provider(s). Department: Tuscola Clinic (Split role: Covering Cardiology and Internal medicine) Hours: Full-time, 40 hours/week Required: ADN, IL-RN, BLS within 90 days of hire Pay: Based on experience, starting at $29.08 Responsibilities Accepts reassignment, at the direction and discretion of management, as applicable to staffing levels and patient volumes , Administers medication as directed by the provider, may provide intravenous therapy., Assessment- Collects pertinent data and information relative to the patient's health or the situation. Recognizes normal and abnormal findings when gathering data. , Assists providers with patient exams/ treatments/procedures, Cleans/stocks exam rooms/work spaces on an on-going basis to assure that there is an adequate supply. Performs all tasks related to stocking and cleaning in adherence to regulatory and system infection control policies/protocols. This includes responsibility for discarding outdated items and labeling multi-dose vials with date and initial opened and then discarding them per guidelines. , Cleans and sterilizes equipment and instruments based on needs of the practice. Performs tasks and documents them in alignment with infection control regulations and system policies/protocols., Coordination of Care- Plans and evaluates care in collaboration with appropriate disciplines for assigned patients., Diagnosis - Analyzes assessment data to determine actual or potential diagnosis, problems, and issues., Documents appropriate data/information. Keeps providers aware of patient requests, needs and observations made that could be of value to the provider's assessment, care and follow-up. , Documents responses to patient history/screening questions for use by providers during assessments and examinations., Evaluation- Evaluates progress toward attainment of goals and outcomes. Reports data and outcomes to as appropriate to physician and/or other disciplines., Follows Universal Precautions at all times during contact with patients, equipment, instruments, and/or specimens., Implementation - Implements care and supervises care delivered by other team members in alignment with the plan of care and approved safety and infection control standards., Knowledge - In collaboration with Leader/Director, actively pursues required knowledge and skills through orientation activities specific to the unit, unit based in-service programs, reading current literature and seeking new clinical learning opportunities. , Obtains provider initials or signature on phone message communications to verify accuracy of information communicated. , Outcomes Identification - Identifies expected outcomes for a plan individualized to the patient or situation., Performs and documents laboratory duties which may include phlebotomy, specimen collection and performance of routine basic waived testing. Handles and coordinates reference lab testing specimens/reports and corresponding reports/documentation., Performs general clerical duties, as required, such as receiving and mailing patient test results, preparing charge tickets, transcribing data to physical or referral forms, filing and monitoring or ordering supplies, , Planning - Develops a plan that prescribes strategies to attain expected, measurable outcomes., Relationships - Establishes effective working relationships with peers, physicians, and other members of the health care team. Identifies and confers with appropriate resources regarding patient care decisions., Relays information between provider(s) and client(s), which may include but is not limited to communications with patients, families, pharmacies, nursing homes, consultancy office staff, insurers, and facilities. At provider's instruction, communicates provider advice, instructions, orders and results, as applicable, including accurate documentation. , Schedules patients for diagnostic, therapeutic, referral or additional office visits., Teaching - Employs teaching strategies to promote health and a safe environment. Requirements ADN (Required)BLS or CPR certification within 90 days of hire. - Sarah Bush Lincoln, RN-Registered Nurse - Illinois Department of Financial and Professional Regulation Compensation Estimated Compensation Range $29.08 - $45.07 Pay based on experience

Full-time

Registered Nurse (RN) Day Shift

apartment Accolade Healthcare of Savoy location_onSavoy, IL

$32 - $40 / hour

About Us At Accolade Healthcare, we put an emphasis on the satisfaction of our team members, understanding that a foundation built on quality patient care starts with the people providing the care. Our goal is to care for our staff with respect, empathy, and appreciation. Providing our professional staff with safe and efficient equipment to complete their mission is our priority. Accolade is committed to never being satisfied with industry norms and standards – instead, always searching for creative methods to equip our team with the tools necessary to achieve success. Job Summary As a Registered Nurse (RN) , you will play a critical role in promoting and restoring patients' health by completing the nursing process. You will collaborate with physicians and multidisciplinary team members, provide physical and psychological support to patients and their families, and supervise assigned team members. A Registered Nurse (RN) ensures the delivery of high-quality care and fosters a compassionate environment for everyone in the healthcare setting. Benefits Benefits: Medical, Dental, Vision and additional other voluntary benefits 401k with company match Generous Paid Leave Policy Free uniforms after hire Daily Pay partner Newly renovated breakrooms - fully stocked beverages Monthly Employee Appreciation Events and Celebrations Duties and Responsibilities As a Registered Nurse (RN) , your responsibilities include: Identifying patient care requirements by establishing personal rapport with patients and their support systems. Establishing a compassionate environment by providing emotional, psychological, and spiritual support to patients and families. Promoting patient independence by: Establishing patient care goals. Teaching patients and families about conditions, medications, and self-care skills. Addressing questions and concerns. Ensuring quality of care by: Adhering to therapeutic standards. Measuring health outcomes against patient care goals and standards. Making or recommending necessary adjustments. Following hospital and nursing division's philosophies and standards of care. Resolving patient problems and needs using multidisciplinary team strategies. Maintaining a safe and clean working environment by: Complying with procedures, rules, and regulations. Calling for assistance from healthcare support personnel as needed. Protecting patients and employees by adhering to infection control policies, medication administration protocols, and controlled substance regulations. Other duties as assigned. Qualifications and Skills To excel as a Registered Nurse (RN) , you will need: Required Qualifications : Associate Degree in Nursing (ADN) or Bachelor’s Degree in Nursing (BSN). Active Registered Nurse (RN) license in good standing with the Illinois Department of Financial and Professional Registry. Skills : Clinical skills, bedside manner, and infection control expertise. Proficiency in administering medication and maintaining health promotion and maintenance. Strong teamwork, multitasking, listening, and verbal communication skills. Physiological knowledge and ability to implement medical teamwork strategies effectively.

Full-time

Registered Nurse (RN) Evening Shift

apartment Accolade Healthcare of Savoy location_onSavoy, IL

$32 - $40 / hour

About Us At Accolade Healthcare, we put an emphasis on the satisfaction of our team members, understanding that a foundation built on quality patient care starts with the people providing the care. Our goal is to care for our staff with respect, empathy, and appreciation. Providing our professional staff with safe and efficient equipment to complete their mission is our priority. Accolade is committed to never being satisfied with industry norms and standards – instead, always searching for creative methods to equip our team with the tools necessary to achieve success. Job Summary As a Licensed Practical Nurse (LPN) , you will play a critical role in promoting and restoring patients' health. Your responsibilities include completing the nursing process, collaborating with physicians and multidisciplinary team members, and providing physical and psychological support to patients, friends, and families. Additionally, you will supervise assigned team members and contribute to maintaining high-quality care. Pay Rate Pay Rate: $32-$40 per hour Benefits Benefits: Medical, Dental, Vision and additional other voluntary benefits 401k with company match Generous Paid Leave Policy Free uniforms after hire Daily Pay partner Newly renovated breakrooms - fully stocked beverages Monthly Employee Appreciation Events and Celebrations Duties and Responsibilities As a Licensed Practical Nurse (LPN) , your responsibilities include: Promoting patients' health by completing the nursing process and collaborating with the care team. Identifying patient care requirements by establishing personal rapport with patients and their support systems. Establishing a compassionate environment by providing emotional, psychological, and spiritual support. Promoting patient independence by: Setting patient care goals. Educating patients and families about conditions, medications, and self-care. Addressing questions and concerns. Ensuring quality of care by: Adhering to therapeutic standards. Measuring health outcomes against goals. Making or recommending necessary adjustments. Resolving patient problems and needs using multidisciplinary team strategies. Maintaining a safe and clean working environment by complying with procedures, rules, and regulations. Protecting patients and employees by adhering to infection control policies, medication administration protocols, and controlled substance regulations. Other duties as assigned. Qualifications and Skills To excel as a Licensed Practical Nurse (LPN) , you will need: A diploma as a Licensed Practical Nurse (LPN) An active Licensed Practical Nurse (LPN) license in good standing with the Illinois Department of Financial and Professional Registry. Clinical expertise, bedside manner, and infection control knowledge. Proficiency in administering medication and maintaining health promotion. Strong teamwork, multitasking, listening, and verbal communication skills. The ability to effectively promote health and maintain patient care standards.