job description
Join MicroSourcing as a Clinical Documentation Improvement (CDI) Nurse Specialist and play a pivotal role in enhancing the accuracy and completeness of medical records. This onsite, night shift position is ideal for dedicated healthcare professionals who thrive in a dynamic environment and are committed to improving patient care through meticulous documentation.
As a CDI Nurse Specialist, you will collaborate with healthcare providers to ensure clinical documentation accurately reflects the severity of illness, risk of mortality, and complexity of care. Your expertise will directly impact the quality of patient care, compliance with regulatory standards, and the financial health of healthcare facilities.
At MicroSourcing, we prioritize your growth and well-being. Enjoy a supportive work environment, competitive compensation, and opportunities for professional development in the beautiful settings of Bali.
Responsibility
- Review and analyze medical records to identify gaps in clinical documentation.
- Collaborate with physicians, nurses, and other healthcare providers to clarify and improve documentation.
- Ensure compliance with coding guidelines, regulatory requirements, and clinical standards.
- Educate healthcare staff on best practices for accurate and thorough clinical documentation.
- Monitor and report on documentation trends to identify areas for improvement.
- Participate in audits and quality assurance initiatives to maintain high standards of documentation.
- Provide real-time feedback to healthcare teams to enhance documentation accuracy.
- Stay updated on changes in healthcare regulations, coding standards, and documentation practices.
Qualifications
- Bachelor's degree in Nursing or related field; active nursing license required.
- Minimum of 3 years of clinical nursing experience, preferably in an acute care setting.
- Certification in Clinical Documentation Improvement (CCDS or CDIP) is a plus.
- Strong understanding of medical terminology, ICD-10, and DRG systems.
- Excellent communication and interpersonal skills to collaborate with healthcare teams.
- Detail-oriented with strong analytical and problem-solving abilities.
- Ability to work independently and manage time effectively in a fast-paced environment.
- Willingness to work night shifts and adapt to onsite requirements.