RN Clinical Documentation Specialist Senior-Full Time

Job Description

The Clinical Documentation Integrity Specialist II(CDI) is responsible for utilizing independent clinical judgement in facilitating the integrity, overall quality, accuracy, and completeness of provider-based clinical documentation in the medical record. This position is responsible for collaborating with healthcare providers to ensure the documentation in the medical record accurately reflects the severity of illness and risk of mortality of the patient. The CDI Specialist assesses the clinical documentation through extensive reviews of the medical record, interaction with all members of the healthcare team and the Healthcare Information Management (HIM) Coding team to ensure appropriate coding and Diagnosis Related Group (DRG) assignment for the level of services rendered to the patient and to ensure that the clinical information utilized in profiling and reporting outcomes is complete and accurate.

Ensures hospital case-mix index and severity profiles are accurate by performing timely medical record review, determination of working Diagnosis Related Group (DRG) assignment and applying clinical expertise to identify opportunities for improved or clarified documentation that accurately reflects the severity of illness (SOI) and risk of mortality (ROM) of the patient. Direct and timely follow-up with clinical providers to ensure requested clarification is provided.

Responsible and accountable for expanding own nursing and Clinical Documentation Integrity (CDI) knowledge (keeping up to date on latest research, technology, treatment modalities, etc.)

Responsible and accountable for reading annual American Health Information Management Association (AHIMA) coding guidelines, updates and understanding of coding clinics.

Responsible and accountable for annual reading of the American Health Information Management Association (AHIMA) Guidelines for Achieving a Compliant Query Practice.

Utilizes critical thinking/problem solving processes.

Appropriately utilizes and interprets professional association resource materials and regulatory agencies guidelines to enhance own skill sets:
Coding Clinics, American Health Information Management Association (AHIMA), Association of Clinical Documentation Integrity Specialists (ACDIS), Centers for Medicare and Medicaid Services (CMS) guidelines.

Identifies concurrent and retrospective query opportunities for medical record integrity.

Working knowledge of compliant query writing so that the question is easily understood by the clinician.

Escalates non-response to query by clinicians immediately according to query escalation policy.

Collaborates with the coding, clinical documentation integrity team and clinical staff.

Demonstrates proficiency in establishing and reconciling Diagnosis Related Group (DRG) processes compliant with departmental guidelines and Centers for Medicare and Medicaid Services (CMS) regulations.

Accurately reconciles all cases in Clinical Documentation Integrity (CDI) database >90% of the time; determined by quality audit

Maintain current clinical documentation integrity specialist production standards as outlined in Centra Health's Health Information Management policy.

Demonstrates good working and background knowledge in reviewing increasingly complex severity of illness (SOI) and risk of mortality (ROM) cases.

Demonstrates proficiency and efficiency in covering all units, specialties, and hospitals

Applies knowledge of health care workflows to work collaboratively with medical staff and other health care team members to improve the overall accuracy and comprehensiveness of medical record documentation, with focus on accurate reporting of quality outcomes.

Good working knowledge of Hospital Acquired Condition (HAC)/Patient Safety Indicator (PSI) query opportunity utilizing resources and follows department guidelines for Hospital Acquired Condition (HAC)/Patient Safety Indicator (PSI) query processes.

Good working knowledge on the impact of accurate clinical documentation in the medical record to establish a working Diagnosis Related Group (DRG): accurate billing, public reporting, research data, quality…