Clinical Documentation Specialist

The Clinical Documentation Specialist (CDI) I, reports to the Market Clinical Documentation Specialist Manager. Under limited direction works collaboratively with medical, nursing and ancillary staff, and case managers and coders to improve the overall accuracy, quality and completeness of clinical documentation in accordance to clinical documentation guidelines and established policies/procedures. The CDI will be responsible for performing initial and follow up reviews of selected patient accounts both while hospitalized or after discharge to identify appropriate documentation accuracy and identify gaps and opportunities to reflect the level of service rendered to all patients.

Ensures the accuracy and completeness of clinical information used for measuring and reporting quality services and performance of specific quality outcomes. Oversees clinical documentation patterns and trends to identify areas of improvement in documentation and performance measures. Educates all members of the patient care team regarding clinical documentation needs, changes to clinical documentation guidelines, coding and reimbursement issues, and quality performance documentation requirements on an on-going basis.

Develops and conducts on-going Performance Documentation education for new staff including case managers, coders, physicians, residents, nursing and allied health professionals. Compiles, analyzes, and evaluates quality and clinical data collected as part of an integrated system-wide program of clinical improvement and documentation requirements. Provide full CDI coverage to the designated facility as per the CDI Department guidelines and directions.

• Facilitates appropriate clinical documentation to support appropriate diagnosis coding and to ensure the level of service rendered to all patients is recorded.
• Collaborates with HIM coding staff to promote complete and accurate clinical documentation and correct negative trends.
• Communicates with physicians, nurse practitioners, case managers, coders and other members of the care team to facilitate comprehensive medical record documentation to reflect treatment, decision-making and medical documentation.
• Assigns a workingMS/APR-DRG and severity level using coding rules and guidelines with follow up reviews as required by LOS standards.
• Analyze clinical information to identify areas within the chart for potential gaps in physician documentation.
• Queries physicians on a concurrent basis. Works with physicians to clarify documentation in the medical record.
• Formulate credible clinical documentation clarifications to improve clinical documentation of principal diagnosis, co-morbidities, present on admission (POA),quality core measures,and patient safety indicators (PSI).
• Conducts post discharge reviews for comparative analysis of CDI Specialist and HIM MS/APR-DRG and severity level assignment. Reviews clinical issues with the coding staff to assign a working DRG.
• Develops and conducts ongoing education for new staff, including newCDISpecialists, physicians and nursing.
• Utilizes software systems (including APR-DRG encoder) to collect, track, and report outcomes. Requires proficiency in abstracting and data entry into all databases used for clinical documentation. Maintains integrity of data collection.
• Participates in ongoing education of staff. Develops educational material and tools relative to documentation improvement practices for individual practitioners and groups of clinicians presented as handouts, PowerPoint, etc.

EDUCATION / EXPERIENCE

Required:

• Graduate from an accredited School of Nursing with RN or LPN,BSN or
• Graduate from an accredited School of Medicine with MD or MBBS (either foreign or domestic),
• And have minimum of 1-year experience working as a CDI in an acute care hospital.

Preferred:

• Graduate from an accredited Health Informatics program for clinical Documentation
• 1–2-years’ experience or more working as a CDI in an acute care hospital
• 3-years’ experience or more in a clinical setting with patient care

REQUIRED CERTIFICATIONS/LICENSURE

Required:

• Either RN, or LPN with an active license
• Or MD, or MBBS

Preferred:

• BSN
• CDI related…