Clinical Documentation Integrity Specialist

Clinical Documentation Integrity Specialist

Join to apply for the Clinical Documentation Integrity Specialist role at St. Joseph's/Candler
.

Key responsibilities and qualifications are outlined below.

• The Clinical Documentation Integrity Specialist is responsible for the concurrent review of inpatient records for timely, accurate, and complete physician documentation.
• Perform concurrent review of patient records analyzing clinical status, current treatment and past medical history to identify potential gaps in physician documentation.
• Conduct follow-up reviews, craft compliant clinical clarification queries to assist physicians to provide more detailed information.
• Establish positive relationships with the clinical team and conduct ad hoc education on documentation and coding issues.
• Responsible for creating and presenting specific clinical topics to the medical providers, clinical staff and HIM team.
• Research and disseminate information on quality measures (AHRQ & APR-DRG metrics). Coordinate with Coding Manager on developing a library of compliant queries.
• Maintain the documentation program database using the 3M program to complete worksheets. Update worksheets and reconcile with final coding.
• Collaborate with HIM to review DRG audits to develop and implement strategies for denials management and improvement of quality outcomes, reimbursement and financial outcomes.
• Prioritize case load on a daily basis. Illustrate the ability to take initiative and good judgment in a self directed role.
• Attend education sessions including in-person, written or webinar. Maintain required credential(s) and continuing education requirements.

• Associate's in Nursing - Required
• Education:
  
  3-5 Years Acute Care Clinical experience - Required; 5-7 Years Acute Care Clinical experience - Preferred
• Registered Nurse License with State of Practice - Required
• ACDIS Certified Clinical Documentation Specialist (CCDS) or AHIMA Certified Documentation Improvement Practitioner (CDIP) - Required at time of offer or when eligible per Association criteria

Mid-Senior level

Full-time

Health Care Provider

Hospitals and Health Care