Clinical Documentation Improvement Specialist

JOB PURPOSE: The primary purpose of the Clinical Documentation Improvement Specialist (CDIS) is to review patient medical records concurrently to ensure accuracy and completeness of documentation. The CDIS is responsible for concurrent review of chart documentation. The CDIS collaborates with physicians, nursing staff, ancillary services, and HIM coding staff to ensure appropriate documentation to facilitate reimbursement for the level of service rendered. The CDIS provides extensive record reviews and interactions with physicians, providers, clinicians/nursing staff, and coders/HIM professionals.

ESSENTIAL FUNCTIONS INCLUDE BUT NOT LIMITED TO:

• Completes initial chart reviews timely to promptly identify potential documentation improvement opportunities.
• Examines patient charts to identify missing information, unclear language, or inconsistencies in documentation that could affect diagnosis coding and reimbursement.
• Evaluates documentation to assign the principal diagnosis, pertinent secondary diagnosis, and procedure codes. for accurate DRG assignment, risk of mortality, and severity of illness
• Conducts follow-up reviews of patients as scheduled to support and assign a working or final DRG.
• Identifies opportunities for documentation improvement to ensure accuracy and completeness of documentation. used for measuring and reporting physician and hospital outcomes
• Communicates with physicians, providers, coders, and other health team members to facilitate comprehensive medical record documentation to reflect medical necessity for clinical treatment, decisions, and diagnoses for inpatients and swing bed patients and document additional services, treatments and stays when medically necessary.
• Queries physicians regarding missing, unclear, or conflicting health record documentation by requesting and obtaining additional documentation within the health record when needed
• Educates physicians and key healthcare providers regarding clinical documentation improvement and the need for accurate and complete documentation in the health record related to compliant documentation responsibilities and coding and reimbursement issues.
• Functions as a trainer in relation to clinical documentation improvement in our EHR system(s); provides guidance and support to providers as needed.
• Collaborates with coding professionals to ensure accuracy of diagnostic and procedural data and completeness of documentation. to determine a working and final DRG.
• Participates in the analysis and trending of statistical data for specified patient populations to identify opportunities for improvement.
• Assists with preparation and presentation of clinical documentation monitoring/trending reports for review.
• Partners with the coding professionals to ensure accuracy of diagnostic and procedural data and completeness of supporting documentation to assign accurate ICD-10-CM/PCS diagnosis and procedure codes.
• Abides by the Health Insurance Portability and Accountability privacy and security regulations regarding all aspects of Protected Health Information (PHI).
• Proficiency in the use of Microsoft applications (e.g. Word and Excel), and Meditech.
• Perform other duties as assigned.

BEHAVIORIAL STANDARDS:

• The individual must support the mission, vision, and goals of Avem Health Partners and serve as a role model within the company.
• Exhibit positive customer service behavior in everyday work interactions.
• Demonstrate a courteous and respectful attitude to internal workforce and external customers.
• Communicate accurately and appropriately.
• Handle difficult situations in a discreet and professional manner.
• Hold self-accountable for professional practice.
• Participate in performance improvement activities utilizing principles to support and improve departmental goals.
• Demonstrate knowledge of unit goals and is active in committees and projects to achieve these goals.
• Keep current with literature regarding changing practices, interventions and best practices.
• Assume responsibility for seeking out educational and professional opportunities for personal learning needs and growth as well as meeting mandatory education requirements.
• Act as a preceptor as requested.
• Demonstrate excellent work attendance and actively participate in a variety of meetings and training sessions as required.
• Adhere to the Avem Health Partners Code of Conduct and Standards of Behavior. Complies with established policies and procedures and all health and safety requirements.

EDUCATION/CERTIFICATION/LICENSURE:

• An active/clear RN license is required for this position. Other medical or clinical backgrounds could be considered as well, including MD, DO, NP, PA etc.
• Certified Documentation Improvement Professional (CDIP) preferred.

POSITION QUALIFICATIONS:

• Minimum 2 years of CDI experience in a hospital or inpatient facility setting is required.
• Ability to read and analyze all aspects of medical record documentation for accurate and complete coding.
• Knowledge in inpatient coding, ICD-10 diagnostic and procedural code assignment.
• Ability to establish cooperative working relationships with medical staff, clinicians, and all other health care disciplines is required.
• Possesses advanced knowledge of medical terminology, anatomy and physiology, disease processes and pharmacology.
• Ability to abstract information from the medical record for indices and statistical reports.
• Familiarity with EMR platforms such as Meditech and Epic is preferred.
• Ability to work independently.

MINIMUM KNOWLEDGE AND SKILL REQUIRED:

• Ability to read, discuss, and interpret information and ideas essential to patient care.
• Excellent oral and written communication
• Basic computer skills and familiarity with Windows based software programs.
• Demonstrated ability to communicate effectively

PHYSICAL REQUIREMENTS:

• To perform this job successfully, an individual must be able to perform each essential job duty satisfactorily. The requirements listed are representative of the knowledge, skill, and/or ability required. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions. Such accommodations must be requested by the employee/applicant to be considered.
• This job requires visual abilities and auditory abilities, must be intact to perform duties.
• Must be able to perform repetitive tasks/motions