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.
Graduate of an accredited school of Registered Nursing required.
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.
Normal office environment.
No expected exposure to blood and/or body fluids.
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.