Clinical Document Improvement Specialist - FT - Day - Clinical Documentation Improvement Trenton NJ

Position Overview

Facilitates improvement of overall quality and completeness of clinical documentation in patient record through extensive interaction with physicians, nursing staff, other patient caregivers, and HIM coding staff. Ensures that medical record documentation provides an accurate representation of the patient's clinical complexity, diagnoses, severity, and expected risk of mortality to support accurate DRG assignment and quality measure reporting.

Minimum Requirements

• Education: Graduate of an accredited school of nursing program. RN, required. BSN preferred.
• Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Practitioner (CDIP) credential preferred.
• Experience: Two years’ recent clinical experience in an acute care setting, preferable ICU or Medical/Surgical, or three years related coding experience or clinical documentation improvement specialist experience in a hospital setting.

Other Credentials

• Strong critical thinking skills and the ability to review the medical record to identify information not yet documented but supported by clinical indicators or clinical clues.
• Excellent verbal and written communication skills.
• Working knowledge of all areas of adult medicine.
• Knowledge of pathophysiology and disease process.
• Intermediate computer skills.
• Familiarity with windows-based software programs and encoding software.

Special Training

• Certification as CCDS or CDIP preferred.

Mental, Behavioral and Emotional Abilities

• Ability to work in environment using multiple EMR systems.
• Excellent observation, analytical thinking, and problem-solving skills.
• Ability to learn/develop skills necessary to perform CDI.
• Flexible, dependable and self-directed.
• Ability to work independently.
• Demonstrates ethical conduct.

Usual Work Day

• 8 Hours

Reporting Relationships

• No

Essential Functions

• Completes initial reviews of patient records within 24-48 hours of admission for a specified patient population to evaluate documentation to assign the principal diagnosis, pertinent secondary diagnoses, and procedures for accurate DRG assignment, risk of mortality, and severity of illness.
• Conducts follow-up reviews of patients every 2-3 days to support and assign a working or final DRG assignment upon patient discharge, as necessary.
• Queries physicians regarding missing, unclear, or conflicting health record documentation by requesting and obtaining additional documentation within the health record when needed.
• Proactively identifies issues with reporting of diagnostic testing.
• Educates physicians and key healthcare providers regarding clinical documentation improvement and the need for accurate and complete documentation in the health record.
• Fosters teamwork and collaboration.
• Mets or exceeds departmental accuracy and productivity standards.
• Attends hospital or Medical Staff meetings to review or respond to documentation related issues.
• Provides technical assistance to the Medical Staff and patient care providers to efficiently navigate the electronic medical which could reside in multiple systems.
• PARTNERS WITH CODING PROFESSIONALS TO ENSURE ACCURACY OF DIAGNOSTIC AND PROCEDURAL DATA AND COMPLETENESS OF SUPPORTING DOCUMENTATION TO DETERMINE A WORKING AND FINAL DRG, SEVERITY OF ILLNESS, AND/OR RISK OF MORTALITY.
• REVIEWS AND CLARIFIES CLINICAL ISSUES IN HEALTH RECORD WITH CODING PROFESSIONALS THAT WOULD SUPPORT AN ACCURATE DRG ASSIGNMENT, SEVERITY OF ILLNESS, AND/OR RISK OF MORTALITY.
• FACTORIES CHANGE PROCESSES REQUIRED TO CAPTURE NEEDED DOCUMENTATIONS, SUCH AS EMR TEMPLATE DESIGN.
• MEETS OR EXCEEDS DEPARTMENTAL ACCURACY AND PRODUCTIVITY STANDARDS.
• ATTENDS HOSPITAL OR MEDICAL STAFF MEETINGS TO REVIEW OR RESPOND TO DOCUMENTATION RELATED ISSUES.
• PROVIDES TECHNICAL ASSISTANCE TO THE MEDICAL STAFF AND PATIENT CARE PROVIDERS TO EFFICIENTLY NAVIGATE THE ELECTRONIC MEDICAL WHICH COULD RESIDE IN MULTIPLE SYSTEMS.
• PARTNERS WITH CODING PROFESSIONALS TO ENSURE ACCURACY OF DIAGNOSTIC AND PROCEDURAL DATA AND COMPLETENESS OF SUPPORTING DOCUMENTATION TO DETERMINE A WORKING AND FINAL DRG, SEVERITY OF ILLNESS, AND/OR RISK OF MORTALITY.
• REVIEWS AND CLARIFIES CLINICAL ISSUES IN HEALTH RECORD WITH CODING PROFESSIONALS THAT WOULD SUPPORT AN ACCURATE DRG ASSIGNMENT, SEVERITY OF ILLNESS, AND/OR RISK OF MORTALITY.
• FACTORIES CHANGE PROCESSES REQUIRED TO CAPTURE NEEDED DOCUMENTATIONS, SUCH AS EMR TEMPLATE DESIGN.
• MEETS OR EXCEEDS DEPARTMENTAL ACCURACY AND PRODUCTIVITY STANDARDS.
• ATTENDS HOSPITAL OR MEDICAL STAFF MEETINGS TO REVIEW OR RESPOND TO DOCUMENTATION RELATED ISSUES.
• PROVIDES TECHNICAL ASSISTANCE TO THE MEDICAL STAFF AND PATIENT CARE PROVIDERS TO EFFICIENTLY NAVIGATE THE ELECTRONIC MEDICAL WHICH COULD RESIDE IN MULTIPLE SYSTEMS.
• PARTNERS WITH CODING PROFESSIONALS TO ENSURE ACCURACY OF DIAGNOSTIC AND PROCEDURAL DATA AND COMPLETENESS OF SUPPORTING DOCUMENTATION TO DETERMINE A WORKING AND FINAL DRG, SEVERITY OF ILLNESS, AND/OR RISK OF MORTALITY.
• REVIEWS AND CLARIFIES CLINICAL ISSUES IN HEALTH RECORD WITH CODING PROFESSIONALS THAT WOULD SUPPORT AN ACCURATE DRG ASSIGNMENT, SEVERITY OF ILLNESS, AND/OR RISK OF MORTALITY.
• FACTORIES CHANGE PROCESSES REQUIRED TO CAPTURE NEEDED DOCUMENTATIONS, SUCH AS EMR TEMPLATE DESIGN.
• MEETS OR EXCEEDS DEPARTMENTAL ACCURACY AND PRODUCTIVITY STANDARDS.
• ATTENDS HOSPITAL OR MEDICAL STAFF MEETINGS TO REVIEW OR RESPOND TO DOCUMENTATION RELATED ISSUES.
• PROVIDES TECHNICAL ASSISTANCE TO THE MEDICAL STAFF AND PATIENT CARE PROVIDERS TO EFFICIENTLY NAVIGATE THE ELECTRONIC MEDICAL WHICH COULD RESIDE IN MULTIPLE SYSTEMS.
• PARTNERS WITH CODING PROFESSIONALS TO ENSURE ACCURACY OF DIAGNOSTIC AND PROCEDURAL DATA AND COMPLETENESS OF SUPPORTING DOCUMENTATION TO DETERMINE A WORKING AND FINAL DRG, SEVERITY OF ILLNESS, AND/OR RISK OF MORTALITY.
• REVIEWS AND CLARIFIES CLINICAL ISSUES IN HEALTH RECORD WITH CODING PROFESSIONALS THAT WOULD SUPPORT AN ACCURATE DRG ASSIGNMENT, SEVERITY OF ILLNESS, AND/OR RISK OF MORTALITY.
• FACTORIES CHANGE PROCESSES REQUIRED TO CAPTURE NEEDED DOCUMENTATIONS, SUCH AS EMR TEMPLATE DESIGN.
• MEETS OR EXCEEDS DEPARTMENTAL ACCURACY AND PRODUCTIVITY STANDARDS.
• ATTENDS HOSPITAL OR MEDICAL STAFF MEETINGS TO REVIEW OR RESPOND TO DOCUMENTATION RELATED ISSUES.
• PROVIDES TECHNICAL ASSISTANCE TO THE MEDICAL STAFF AND PATIENT CARE PROVIDERS TO EFFICIENTLY NAVIGATE THE ELECTRONIC MEDICAL WHICH COULD RESIDE IN MULTIPLE SYSTEMS.
• PARTNERS WITH CODING PROFESSIONALS TO ENSURE ACCURACY OF DIAGNOSTIC AND PROCEDURAL DATA AND COMPLETENESS OF SUPPORTING DOCUMENTATION TO DETERMINE A WORKING AND FINAL DRG, SEVERITY OF ILLNESS, AND/OR RISK OF MORTALITY.
• REVIEWS AND CLARIFIES CLINICAL ISSUES IN HEALTH RECORD WITH CODING PROFESSIONALS THAT WOULD SUPPORT AN ACCURATE DRG ASSIGNMENT, SEVERITY OF ILLNESS, AND/OR RISK OF MORTALITY.
• FACTORIES CHANGE PROCESSES REQUIRED TO CAPTURE NEEDED DOCUMENTATIONS, SUCH AS EMR TEMPLATE DESIGN.
• MEETS OR EXCEEDS DEPARTMENTAL ACCURACY AND PRODUCTIVITY STANDARDS.
• ATTENDS HOSPITAL OR MEDICAL STAFF MEETINGS TO REVIEW OR RESPOND TO DOCUMENTATION RELATED ISSUES.
• PROVIDES TECHNICAL ASSISTANCE TO THE MEDICAL STAFF AND PATIENT CARE PROVIDERS TO EFFICIENTLY NAVIGATE THE ELECTRONIC MEDICAL WHICH COULD RESIDE IN MULTIPLE SYSTEMS.
• PARTNERS WITH CODING PROFESSIONALS TO ENSURE ACCURACY OF DIAGNOSTIC AND PROCEDURAL DATA AND COMPLETENESS OF SUPPORTING DOCUMENTATION TO DETERMINE A WORKING AND FINAL DRG, SEVERITY OF ILLNESS, AND/OR RISK OF MORTALITY.
• REVIEWS AND CLARIFIES CLINICAL ISSUES IN HEALTH RECORD WITH CODING PROFESSIONALS THAT WOULD SUPPORT AN ACCURATE DRG ASSIGNMENT, SEVERITY OF ILLNESS, AND/OR RISK OF MORTALITY.
• FACTORIES CHANGE PROCESSES REQUIRED TO CAPTURE NEEDED DOCUMENTATIONS, SUCH AS EMR TEMPLATE DESIGN.
• MEETS OR EXCEEDS DEPARTMENTAL ACCURACY AND PRODUCTIVITY STANDARDS.
• ATTENDS HOSPITAL OR MEDICAL STAFF MEETINGS TO REVIEW OR RESPOND TO DOCUMENTATION RELATED ISSUES.
• PROVIDES TECHNICAL ASSISTANCE TO THE MEDICAL STAFF AND PATIENT CARE PROVIDERS TO EFFICIENTLY NAVIGATE THE ELECTRONIC MEDICAL WHICH COULD RESIDE IN MULTIPLE SYSTEMS.
• PARTNERS WITH CODING PROFESSIONALS TO ENSURE ACCURACY OF DIAGNOSTIC AND PROCEDURAL DATA AND COMPLETENESS OF SUPPORTING DOCUMENTATION TO DETERMINE A WORKING AND FINAL DRG, SEVERITY OF ILLNESS, AND/OR RISK OF MORTALITY.
• REVIEWS AND CLARIFIES CLINICAL ISSUES IN HEALTH RECORD WITH CODING PROFESSIONALS THAT WOULD SUPPORT AN ACCURATE DRG ASSIGNMENT, SEVERITY OF ILLNESS, AND/OR RISK OF MORTALITY.
• FACTORIES CHANGE PROCESSES REQUIRED TO CAPTURE NEEDED DOCUMENTATIONS, SUCH AS EMR TEMPLATE DESIGN.
• MEETS OR EXCEEDS DEPARTMENTAL ACCURACY AND PRODUCTIVITY STANDARDS.
• ATTENDS HOSPITAL OR MEDICAL STAFF MEETINGS TO REVIEW OR RESPOND TO DOCUMENTATION RELATED ISSUES.
• PROVIDES TECHNICAL ASSISTANCE TO THE MEDICAL STAFF AND PATIENT CARE PROVIDERS TO EFFICIENTLY NAVIGATE THE ELECTRONIC MEDICAL WHICH COULD RESIDE IN MULTIPLE SYSTEMS.
• PARTNERS WITH CODING PROFESSIONALS TO ENSURE ACCURACY OF DIAGNOSTIC AND PROCEDURAL DATA AND COMPLETENESS OF SUPPORTING DOCUMENTATION TO DETERMINE A WORKING AND FINAL DRG, SEVERITY OF ILLNESS, AND/OR RISK OF MORTALITY.
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