CentraState Healthcare System

  • Clinical Documentation Improvement Specialist (CDI)

    Posted Date 3 weeks ago(3 weeks ago)
    ID
    2018-8768
    Position Type
    Regular Full-Time
    Location
    CentraState Medical Center
    Shift
    Day
    Work Schedule
    9A-5P
  • Overview

    The Clinical Documentation Improvement Specialist (CDIS) will perform concurrent analytical review of clinical and coding data with a goal of improving physician documentation for all conditions and treatments from point of entry to discharge, ensuring an accurate reflection of the patient condition in 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. Finally, 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.

    Responsibilities

    • Collaborates with the 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.
    • Educates 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.
    • Facilitates and obtains appropriate physician documentation including resolution of queries for any clinical conditions or procedures.
    • Performs concurrent analytical review of clinical and coding data with a goal of improving physician documentation for all conditions and treatments.
    • Facilitates concurrent modifications to clinical documentation to support care provided.
    • Conducts follow-up documentation reviews to ensure clarification has been recorded in the patient's chart.
    • Reviews clinical issues with coding staff, nurses and others to ensure appropriate inpatient technical diagnosis and procedural coding.
    • Seeks opportunities to discuss cases with physicians/providers at meetings, rounding and medical staff meetings.
    • Maintains a collaborative working relationship with quality, case management and HIM staff.
    • Inputs activities from concurrent reviews into CDI software and ensures consistency of data captured.
    • Familiarity with MS-DRGs and the Inpatient Prospective Payment System (IPPS), including new CMS guideline of key elements including clinical documentation of what constitutes an inpatient admission.

    Qualifications

    Education:

    BSN preferred.

    Graduate of an accredited school of Registered Nursing required.

     

    Experience:

    Two years of clinical experience in a healthcare environment required.

    One year of coding experience a plus.

     

    Licenses and Certifications:

    Current NJ RN License required.

    CCDS must be obtained within two years of hire.

    Certified Coding Specialist designation (CCS, CSS, CCS-P from AHIMA) preferred.

     

    Required Knowledge and Skills:

    Strong broad-based clinical knowledge and understanding of pathology/physiology of disease processes. Excellent written and verbal communication skills, Excellent critical thinking skills. Excellent interpersonal skills to build effective partnering relationships with physicians, nurses, and hospital staff. Ability to work independently in a time oriented environment. Working knowledge of inpatient admission criteria. Working knowledge of Medicare reimbursement system and coding structures desired. An understanding of coding classifications systems such as, but not limited to, ICD-9/10CM, APR-DRG preferred. Knowledge of care delivery documentation systems and related medical record documentation. Prior documentation specialist experience preferred.

    Physical Demands

    Working Conditions:

    Normal office environment.

     

    Exposure:

    No expected exposure to blood and/or body fluids.

     

    Physical Demands:

    Sitting - Continuously

    Standing/Walking - Rarely

    Kneeling/Stooping - Rarely

    Bending/Climbing - Rarely

    Reaching above shoulder, at waist or below waist - Rarely

    Lifting/Pushing or Pulling up to 40 pounds - Never

    Lifting/Pushing or Pulling over 40 pounds – Never

    Typing/Filing - Continuously

     

    Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

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