Clinical Documentation Integrity Specialist - Days

Full Time (80 Hours Biweekly)

Days

Job Description:

Under the general supervision of the Manager-Clinical Documentation Integrity, the Clinical Documentation Integrity (CDI) Specialist is responsible for facilitating the improvement in the overall quality and completeness of provider-based clinical documentation in the medical record. Assists treating providers to ensure that documentation in the medical record accurately reflects the severity of illness of the patient as well as the level of services rendered. Assesses clinical documentation through extensive review of the medical record, interaction with providers, nursing staff, other patient care givers, and Health Information Management (HIM) coding staff to ensure that appropriate reimbursement is received for the level of services rendered to patients and the clinical information utilized in profiling and reporting outcomes is complete and accurate.

Duties and Responsibilities

Essential Accountabilities:

1. Reviews medical records of hospitalized patients to identify the most appropriate principal diagnosis and to assign a working Diagnosis Related Group (DRG). Performs initial reviews, concurrent reviews, and retrospective reviews to ensure the DRG accurately reflects the principal diagnosis and all comorbid conditions after study.
2. Performs initial case reviews and appropriate number of follow-up reviews based on program standards.
3. Completes initial and follow-up medical record reviews using an organized approach to survey admit notes, past medical history, home meds, physician/provider documentation, treatments, orders, ancillary department notes, laboratory data, and other pertinent components of the clinical record.
4. Completes the initial review, pulling cases by prioritization.
5. Completes concurrent reviews to ensure working DRG and all comorbid conditions are documented by the providers to the greatest specificity.
6. Using clinical insight and judgment, analyzes and interprets clinical data to identify gaps, inconsistencies, and/or opportunities for improvement in the clinical documentation and appropriately queries the provider per guidelines.
7. Formulates credible clinical documentation clarifications to improve clinical documentation of principal diagnosis, co-morbidities, present on admission (POA), quality core measures, hospital acquired conditions (HAC), and patient safety indicators (PSI).
8. Follows each query through to closure including complete documentation of ongoing follow up activities and communication.
9. Maintains integrity and compliance in all chart reviews and queries.
10. Collaborates with the coding staff concurrently and retrospectively to ensure the chart has all the necessary documentation to support the most accurate coding.
11. Develops and supports strong professional relationships with Clinical Documentation Integrity Specialists (CDS), coding staff, compliance, quality, and medical providers across the system.
12. Works collaboratively with medical, nursing, and ancillary staffs to improve the quality of chart documentation that assures appropriate DRG classification to accurately reflect patient severity of illness and risk of mortality and anticipated/geometric mean length of stay (GMLOS).
13. Demonstrates an understanding of complications, co-morbidities, severity of illness (SOI), risk of mortality (ROM), case mix, secondary diagnosis, impact of procedures on the final DRG, and an ability to impart this knowledge to physicians and other members of the healthcare team.
14. Provides CDI education to providers one on one, during staff meetings, or during department meetings.
15. Provides ongoing CDS team learning opportunities through sharing of professional knowledge.
16. Functions as a subject matter expert and actively participates in meetings as a problem-solver.
17. Facilitates and/or supports continuous improvement activities.
18. Supports and implements quality measures as identified by department manager.
19. Maintains professional competency by keeping abreast of new coding issues and guidelines.
20. Uses software systems (including APR-DRG encoder) to collect, track, and report outcomes. Requires proficiency in abstracting and data entry into all databases used for clinical documentation.

NonEssential Accountabilities:

1. Prepares and presents data analysis as required.
2. Assists with special projects and attends meetings as needed.
3. Performs other related duties as identified.

Common Expectations:

1. Prepares and maintains appropriate documentation as required.
2. Maintains professional growth and development through seminars, workshops, and professional affiliations to keep abreast of latest trends in field of expertise.
3. Provides outstanding service to all customers; fosters teamwork; and practices fiscal responsibility through improvement and innovation

Qualifications

• Notes:
  • Other combinations of formal education, training and experience may be considered.
• Minimum Experience:
  • RN without CDI experience: 5 years recent hospital experience with Critical Care experience; OR CDI experience as a concurrent or retrospective documentation specialist in an inpatient acute care facility.
• Minimum Education:
  • Bachelor’s Degree or pursuing
• Preferred Experience:
  • Preferred ExperienceClinical Documentation Integrity
• Required Certification:
  • RN, MD, DO or APP (PA or CRNP) with current license in PA; AND/OR a Medical Degree with experience as a concurrent or retrospective specialist in an inpatient acute care facility
• Preferred Certification:
  • CCDS or CDIP
• Physical Demands:
  • Mostly sedentary work
  • Occasional prolonged standing/walking
• Skills:
  • Organized, analytical, self-directed with critical thinking, problem solving and deductive reasoning skills; computer skills; experience with PowerPoint. Excel, and Microsoft Office
  • Self-directed and motivated to function both independently and on teams.