What are the responsibilities and job description for the Clinical Documentation Integrity Specialist position at Great Plains Health?
Position Summary
Education
o Graduate of an accredited school of nursing
Credentials
o State Required: RN license in the State of Nebraska required.
o GPH Required/Preferred: CDI experience preferred
Physical Demands
1. Stand and/or walk up to two hours per day.
2. Sit up to six hours per day.
3. Lift and/or carry up to 10 pounds daily.
4. Bend and reach throughout the day.
5. Visual acuity required.
Essential Functions
1. Appropriately utilizes and interprets professional association resource materials and regulatory agencies guidelines to enhance own skill sets: Coding Clinics, AHIMA, ACDIS, CMS guidelines
2. Identifies concurrent query opportunities for record integrity.
3. Exhibits superior skill in identifying and addressing complex documentation improvement opportunities such as cases at risk for HAC/PSI.
4. Provides service line directed education to provider teams.
5. Demonstrates comprehension of CMI and can interpret, analyze, evaluate data, provide rationale for trends/impacting factors and develop strategy for correcting/optimizing CMI
6. Actively participates in advancing the CDI practice for facility or corporate by developing/modifying/implementing/educating/evaluating new practice behaviors, guidelines, technology enhancements (query format, quality measurement tools-criteria, guideline)
7. Exhibits excellent skills in query composition and mechanics that are clear, concise and masterful in providing accurate documentation support.
- The CDI Specialist position is responsible for collaborating with healthcare providers to ensure the documentation in the medical record accurately reflects the severity of illness and risk of mortality of the patient. The CDI Specialist assesses the clinical documentation through extensive reviews of the medical record, interaction with all members of the healthcare team, Quality department and the Health Information Management (HIM) Coding teams to ensure appropriate coding and DRG assignment for the level of services rendered to the patient and to ensure that the clinical information utilized in profiling and reporting outcomes is complete and accurate.
Education
o Graduate of an accredited school of nursing
Credentials
o State Required: RN license in the State of Nebraska required.
o GPH Required/Preferred: CDI experience preferred
Physical Demands
1. Stand and/or walk up to two hours per day.
2. Sit up to six hours per day.
3. Lift and/or carry up to 10 pounds daily.
4. Bend and reach throughout the day.
5. Visual acuity required.
Essential Functions
1. Appropriately utilizes and interprets professional association resource materials and regulatory agencies guidelines to enhance own skill sets: Coding Clinics, AHIMA, ACDIS, CMS guidelines
2. Identifies concurrent query opportunities for record integrity.
3. Exhibits superior skill in identifying and addressing complex documentation improvement opportunities such as cases at risk for HAC/PSI.
4. Provides service line directed education to provider teams.
5. Demonstrates comprehension of CMI and can interpret, analyze, evaluate data, provide rationale for trends/impacting factors and develop strategy for correcting/optimizing CMI
6. Actively participates in advancing the CDI practice for facility or corporate by developing/modifying/implementing/educating/evaluating new practice behaviors, guidelines, technology enhancements (query format, quality measurement tools-criteria, guideline)
7. Exhibits excellent skills in query composition and mechanics that are clear, concise and masterful in providing accurate documentation support.
Location: Great Plains Health · Quality Management
Schedule: Full Time, Day Shift
