Description

Job Purpose

The Clinical Documentation Improvement Specialist focuses on the accuracy, completeness and consistency of inpatient clinical documentation to support coding and reporting of high-quality healthcare data. The Clinical Documentation Improvement Specialist performs concurrent chart reviews to validate that the clinical documentation in the medical record appropriately describes the patient’s severity of illness, complexity of care, and risk of mortality to facilitate appropriate coding. The Clinical Documentation Improvement Specialist utilizes advanced knowledge of disease processes, medications, and has critical thinking to analyze current documentation to identify gaps in clinical documentation. The Clinical Documentation Improvement Specialist facilitates appropriate modifications to documentation through extensive interactions and collaborations with providers, coding, quality, and case management teams. This team member serves as an effective change agent as a resource and educator for providers and interdisciplinary care teams. 

Duties and Responsibilities

Analyzes medical records to identify incomplete or inaccurate documentation related to diagnoses, treatments, and procedures.
Periodically analyzes coding data to identify documentation variations and determine the cause and appropriateness of such variation; presents such findings to the management.  
Performs concurrent chart reviews to validate that the clinical documentation in the medical record appropriately describes the patient’s severity of illness, complexity of care, and risk of mortality to facilitate appropriate coding.
Works closely with physicians, nurses, and other healthcare professionals to clarify and obtain additional information needed for accurate documentation.
Facilitates modification to clinical documentation supporting the clinical picture/level of severity rendered to all patients at the Hospital for DRG based payers through concurrent interactions with physicians and other members of the health care team. 
Collaborates with healthcare providers, physicians, nurses, and other stakeholders to clarify and improve documentation.
Provids support to medical coders by ensuring documentation supports the assigned codes and compliance with coding guidelines.
Communicates effectively with coding teams to address coding-related issues and promote accurate code assignment.
Conducts training sessions for healthcare staff on proper documentation practices, coding guidelines, and compliance requirements, as requested by CDI manager
Utilizes data analytics to identify trends, patterns, and areas for improvement in documentation accuracy and completeness.
Monitors daily DRG assignment, DRG reports and tracking areas for performance improvement to appropriately reflect optimal severity at admission and through the stay. 
Demonstrates an understanding of current Quality Measure Initiatives including Value Based Purchasing, Pay for Performance, and Readmission criteria. 
Ensures documentation aligns with regulatory requirements, coding standards, and healthcare policies.
Conducts regular audits to assess the quality of clinical documentation and identifying areas for improvement.
Participates in quality improvement initiatives related to clinical documentation and coding accuracy.
      Use, protect and disclose patients’ protected health information (PHI) only in accordance with Health Insurance Portability and Accountability Act (HIPAA) standards.

      Limit viewing of PHI to the absolute minimum as necessary to perform assigned duties

      Understand and comply with Information Security and HIPAA policies and procedures at all times

      Limit viewing of PHI to the absolute minimum as necessary to perform assigned dut

Requirements

Minimum of 3 years of experience in clinical documentation improvement role - adult acute care experience in med/surg, critical care, emergency, or PACU
Certification minimum requirement – RN, CCDS and/or CDIP
RN with coding credential highly preferred
Coding credential highly preferred (CCS, CPC, CCS-P)
Current state Registered Nurse license highly preferred
Clinic Fundamental knowledge of ICD-10 Official Coding Guidelines and DRG Reimbursement Systems
Demonstrated skills in analytical thinking, problem solving
Excellent communication and people skills.
Self-motivated and able to work independently without close supervision
Proficient in the use of computers including Microsoft Office (Word, Excel, PowerPoint, etc.), Outlook, and other applications necessary to perform the CDS role such as an encoder or CDI workflow and reporting tool.