General Summary of PositionEnsures that documentation supports accurate, complete and consistent, unambiguous clinical documentation. Utilizes clinical expertise to support appropriate reflection of the patient's risk of mortality and severity of illness. Develops compliant physician queries guided by the American Health Information Management Associations (AHIMA) Ethical Standards for Clinical Documentation Improvement Professionals,the ACDIS/AHIMA Query practice brief, and state, federal, and other appropriate regulatory guidance. Evaluates the medical records for case specific review including mortalities, complications, quality of care, and other needs identified requiring review and/or second level review. Reviews and analyzes inpatient record for compliant documentation. Provides education to all levels of clinical staff. Closely collaborates with coding professionals to ensure appropriate ICD-10 and DRG assignment. Maintains certification and credentials applicable to the Clinical Documentation Integrity Specialist role. Monitors clinical case data to identify areas of improvement.
Primary Duties and Responsibilities
Contributes to the achievement of established department goals and objectives and adheres to department policies, procedures, quality standards and safety standards. Complies with governmental and accreditation regulations.Demonstrates a cooperative, collaborative and team-oriented approach with CDI team, coders, nursing staff, medical staff and all other ancillary departments. Communicates effectively to ensure a coordinated, standardized and effective approach with clinicians.Demonstrates the appropriate utilization of paper and electronic CDI chart review resources to foster transition of cases within the CDI team. Ensures the CDI work sheet includes precise clinical details, appropriate data entry into software, and complete and updated code set to support physician queries and support case review decisions.Develops written and verbal CDI physician queries, in compliance with AHIMA/ACDIS query practice brief and other appropriate regulatory body requirements. Identifies opportunities for education based upon query topics or other identified need and provides on-going education to physicians, clinicians and other stakeholders about the need for accurate, complete and consistent documentation in the medical record.Inputs daily review data in a timely manner including number of cases reviewed, number of queries placed, working MS-DRG or APR-DRG, secondary diagnoses, procedures, and determination of MS-DRG or APR-DRG.Maintains continuing education and credentials for clinical documentation integrity specialist job classification.Meets the organizations CDS performance standards including, but not limited to, productivity (initial reviews and follow up reviews), query rate, and documentation clarification rate.Participates in identifying areas of opportunity to improve the success or mitigate barriers in the CDI program and collaborates with the CDI Director to develop action plans to address issues.Participates in meetings and on committees and represents the department and hospital in community outreach efforts as required.Participates in the collection, analysis and trending of CDI data to identify opportunities for improvement and to develop education for medical and hospital staff.May be asked to participate in the retrospective review of principal and secondary diagnoses to ensure the accuracy of diagnostic and procedural data.Performs initial and follow-up CDI chart reviews in accordance to the Hospitals CDI Policies and Procedures.Performs quality chart reviews in accordance to the Hospital CDI policies and procedures. Ability to recognize and research clinically complex conditions and associated global exclusions. Utilizes coding and CDI resources in an effort to apply the correct coding guidelines and clinical information to the review of the patients record.Performs other duties as assigned.Provides input in the development of power plans, best practice guidelines and power notes within the hospital EMR systems to facilitate adherence to best practices and regulatory requirements.Reviews the medical record and evaluates the documentation to assign the Principal Diagnosis, pertinent secondary diagnoses and procedures for accurate MS-DRG or APR-DRG assignment/Severity of Illness and Risk of Mortality.
Minimum Qualifications Education
- Associate's degree in Nursing required or
- Bachelor's degree in Nursing preferred or
- Master's degree Nursing or other clinically focused field of study such as Advanced Practice Nursing, Physician Assistant preferred or
- Doctoral degree Foreign Medical Graduate preferred
Experience
- 3-4 years Experience in acute care setting required and
- Experience in ICD-10 coding review and DRG reimbursements systems preferred
Licenses and Certifications
- Cert Docum Improv Practitioner - CDIP Upon Hire required or
- CCDS - Certified Clinical Documentation Specialist Upon Hire required and
- CCS-Certified Coding Specialist preferred
Knowledge, Skills, and Abilities
- Proficient in Microsoft Office applications (Word, Excel, PowerPoint).
- Excellent interpersonal skills, including verbal and written communication.
- Ability to collect and analyze data related to the CDI program.
- Proficient in reviewing medical records and understanding pertinent clinical information.
- Ability to demonstrate critical-thinking skills.
This position has a hiring range of $87,318 - $157,289