System Clinical Documentation Information Specialist

Overview

Job Description - System Clinical Documentation Information Specialist (1893) (1612119)

Lander Regional Hospital

Description

The System Clinical Documentation Specialist (CDI) at Sage West will facilitate improvement in the overall quality, completeness, and accuracy of clinical documentation. Through concurrent interaction with physicians, case managers, coders and other health care team members, the Clinical Documentation Specialist will strive to ensure comprehensive medical record documentation that reflects the clinical treatment, decisions, and diagnosis for all inpatients. Serving as a resource to all members of the health care team on documentation guidelines, this position will provide guidance and support, as well as assisting with education and training related to improving clinical documentation.

This position will actively participate in educating appropriate hospital and medical staff about the changes associated with transitioning to ICD-10.

Note:

The original text emphasizes the role of facilitating documentation quality and acting as a resource, education, and support related to ICD-10 transitions. Specific bullet points were not provided in the source; this section preserves the intent in paragraph form.

• Licensed Registered Nurse, RHIA, RHIT, CCS, LPN or combination thereof preferred.
• Prior experience in case management, utilization review, clinical documentation improvement, and/or coding accuracy preferred.
• Minimum of five years’ experience in an acute adult in-patient clinical role for RNs and LPNs with demonstrated critical thinking skills or a minimum of two years’ experience with inpatient coding for coders, process improvement in an acute care facility preferred or equivalent experience.
• Coding skills with experience in ICD-9-CM, knowledge of CMS Inpatient Prospective Payment System, and working knowledge of AHA Coding Clinic.
• Current licensure as a registered nurse in state of practice (if applicable)
• Certified Clinical Documentation Improvement Specialist (CCDS) or Certified Documentation Improvement CDI Practioner highly preferred.
• Proven communication skills in dealing with multidisciplinary clinical and operations teams including physicians.
• Current working knowledge of one or more of the following:
  Medical /Surgical Nursing, Critical Care, Care and Case Management (Resource Utilization), Surgical Services, Accreditation and Regulatory Compliance, Core Measures and Public Reporting of Hospital Quality Data.