Clinical Documentation Improvement Specialist; On-site in Carroll, Iowa

Position: Clinical Documentation Improvement Specialist (On-site in Carroll, Iowa)
Clinical Documentation Improvement Specialist

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Clinical Documentation Improvement Specialist

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• Promotes accurate, complete and timely clinical documentation by conducting regular evaluations of documentation in accordance with CDI policies and procedures.
• Conducts real-time reviews of clinical documentation to ensure accuracy, completeness, and compliance with CDI policies and regulatory standards.
• Participates in physician rounds and remains available throughout the day for real-time provider collaboration.
• Issues queries in a professional and timely manner to clarify ambiguous, conflicting, or incomplete documentation.
• Ensures documentation supports patient acuity, severity of illness, risk of mortality, case mix index, and appropriate reimbursement.
• Maintains proficiency in CMS guidelines, third-party payer requirements, coding rules, and documentation standards.
• Demonstrates understanding of clinical indicators, disease processes, complications, and co-morbidities.
• Submits reports reflecting query activity, trends, and cost impact as required (e.g., monthly and quarterly).
• Maintains a positive, respectful approach when interacting with physicians, nurses, HIM, coders, payers, patients, and families.
• Adheres to Quality Management protocols for productivity and documentation integrity.
• Promotes continuous improvement by identifying documentation-related issues and contributing to process enhancements.
• Remains current on trends in CDI practices through continuing education and training.
• Complies with all applicable federal, state, and organizational regulations and standards (e.g., HIPAA, CMS, JCAHO).
• Follows safe work practices and maintains a clean, hazard-free work environment.
• Maintains confidentiality of all patient, employee, and organizational information.
• Performs other duties as assigned.

Job Details

Description



Essential Duties and Responsibilities

• Promotes accurate, complete and timely clinical documentation by conducting regular evaluations of documentation in accordance with CDI policies and procedures.
• Conducts real-time reviews of clinical documentation to ensure accuracy, completeness, and compliance with CDI policies and regulatory standards.
• Participates in physician rounds and remains available throughout the day for real-time provider collaboration.
• Issues queries in a professional and timely manner to clarify ambiguous, conflicting, or incomplete documentation.
• Ensures documentation supports patient acuity, severity of illness, risk of mortality, case mix index, and appropriate reimbursement.
• Maintains proficiency in CMS guidelines, third-party payer requirements, coding rules, and documentation standards.
• Demonstrates understanding of clinical indicators, disease processes, complications, and co-morbidities.
• Submits reports reflecting query activity, trends, and cost impact as required (e.g., monthly and quarterly).
• Maintains a positive, respectful approach when interacting with physicians, nurses, HIM, coders, payers, patients, and families.
• Adheres to Quality Management protocols for productivity and documentation integrity.
• Promotes continuous improvement by identifying documentation-related issues and contributing to process enhancements.
• Remains current on trends in CDI practices through continuing education and training.
• Complies with all applicable federal, state, and organizational regulations and standards (e.g., HIPAA, CMS, JCAHO).
• Follows safe work practices and maintains a clean, hazard-free work environment.
• Maintains confidentiality of all patient, employee, and organizational information.
• Performs other duties as assigned.

Supervisory Responsibilities

This job has no supervisory responsibilities.

Qualifications

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge,…