Clinical Documentation Improvement Specialist (Part time .8 FTE)

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POSITION SPECIFICS

Title: Clinical Documentation Improvement Specialist (part-time .8 FTE)

FTE: .8 FTE (32 hours per week)

Schedule: Flexible hours worked between Monday to Friday, 8:00am to 4:30pm

Holiday Rotation: None

Weekend Rotation: None

On Call Requirements: None

Location: Hybrid position; primarily remote for state of WI resident, on-site based on business needs

POSITION SUMMARY

Under the direction of the Director – Revenue Cycle, the Clinical Documentation Improvement Specialist (CDIS) is responsible for developing and implementing systems designed to improve the overall quality and completeness of clinical documentation.

The CDIS will perform concurrent analytical review of clinical data with a goal of improving provider documentation for all conditions and treatments from point of entry to discharge, ensuring an accurate reflection of the patient condition and the associated DRG assignments, case-mix index, severity of illness & risk of mortality profiling, and reimbursement.

The CDIS will facilitate the resolution of queries as well as educate members of the patient care team regarding documentation guidelines and the need for accurate and complete documentation in the health record, including attending physicians, allied health practitioners, nursing, and case management.

The CDIS will collaborate with coding professionals to ensure accuracy of diagnostic and procedural data and completeness of supporting documentation to determine a working and final DRG, severity of illness, and/or risk of mortality.

POSITION TECHNICAL RESPONSIBILITIES

• Promotes appropriate clinical documentation through extensive interaction with providers, nursing staff, other clinical staff, and coding staff to ensure that the documentation of the level of service rendered to the patient and the patient’s clinical complexity is complete and accurate.
• Reviews clinical documentation and identifies potential gaps on admission and throughout the hospitalization.
• Rounds with providers to provide just-in-time education and support for appropriate clinical documentation.
• Participates in interdisciplinary rounds, promotes enhanced communication between team members through identification of undocumented and under documented clinical conditions.
• Promotes awareness of relevant clinical information not previously identified by the clinical team.
• Queries providers and other clinical staff as necessary via approved written communication mechanisms to obtain accurate and complete documentation that supports the severity of patient illness, intensity of services and risk of mortality.
• Performs thorough chart review to assure that co morbidities, complications and conditions present on admission are documented. Obtains and/or clarifies missing, unclear or conflicting documentation within the health record from the provider prior to discharge.
• Remains current with relevant quality abstraction and coding guidelines and requirements.
• Analyzes patterns and trends in clinical documentation and provides focused education providers and clinical staff on an as needed basis. Provides feedback to providers and individual departments regarding outcomes for key indicators.
• Provides routine education for providers and the clinical care team regarding evolving and relevant clinical documentation requirements and improvement opportunities.
• Analyses documentation workflow. Identifies systematic barriers to accurate and complete documentation. Collaborates with providers and other clinical leaders to design and implement electronic tools such as best practices, discharge reminders and order sets that promote evidence-based care.
• Participates in the Utilization Review Committee, Interdisciplinary Team meetings and other medical staff committees as assigned.
• Performs other duties as assigned.

POSITION REQUIREMENTS

Education:

• Required: High school diploma, or equivalent
• Preferred: Degree in nursing or Health Information Technology. Degree in other healthcare-related field acceptable.

Experience:

• Required:
• Preferred:

Licenses and Registrations:

• Required: None
• Preferred:

Certification(s):

• Required: None
• Preferred: Certification as either a Clinical Documentation Improvement Practitioner (CDIP) through the American Health Information Management Association or Certified Clinical Documentation Specialist (CCDS) through Association of Clinical Documentation Improvement Specialists.

Knowledge/Skills:

• Skill in establishing and maintaining effective working relationships with employees and customers.
• Ability to work independently and as a team member; possesses excellent listening, analytical, and time management skills.
• Possesses strong leadership and interpersonal skills, including both written and verbal communication skills.
• Knowledge of medical terminology.
• Knowledge of disease/procedure classification systems such as DRGs, ICD – CM, and CPT coding desirable.
• Knowledge of anatomy and physiology to support clinical review.
• Skilled working with Windows based applications including word processing, spreadsheets, and presentation software.

BENEFIT SUMMARY

• Competitive health and dental insurance options
• Flexible paid time off to balance work and life
• Retirement plan with immediate vesting and employer match
• Discounted membership to our state-of-the-art fitness facility
• Generous tuition reimbursement
• Employer provided life and disability insurance
• Free parking at facility

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