Clinical Document Integrity Specialist

About the role

The CDIS will facilitate modifications to clinical documentation, through extensive concurrent chart review, interactions with physicians and other clinicians, in order to ensure accurate documentation of diagnosis and procedures, reflection of appropriate clinical severity, clarification of complications and conflicting documentation, and capture of co-morbid conditions. The CDIS will complete majority of concurrent reviews to evaluate selected patient's medical records for overall quality and completeness.

Responsibilities

• Utilize extensive knowledge of documentation requirements and guidelines in accordance with Coding Clinic to improve the overall quality and completeness of clinical documentation by performing concurrent stay reviews.
• Utilize client technology to track documentation notes and observations, assign Working DRG and calculate Query DRG to reflect impact of queries initiated, complete query entry for tracking purposes and complete validation process to ensure diagnosis located in EMR or attained by query are final coded.
• Education of physicians, non-physician clinicians, nurses and coding staff on an ongoing basis regarding documentation opportunities, coding and reimbursement issues and relevant quality and performance improvement opportunities.
• Aid team in meeting and exceeding high performing CDI program metrics.

Requirements

• Clinical candidates: Licensed as a Registered Nurse with an Associate Degree (ADN) or Bachelor’s degree in Nursing (BSN), or an MD. At least three (3) years of recent acute care nursing experience required. ICU or ED experience preferred. Clinical expertise required.
• HIM professional candidates: Credentialed as an RHIA, RHIT, CPC, or CCS and have experience in ICD 10 coding. At least three (3) years of clinical coding and/or auditing experience in a hospital environment.

Qualifications

• Computer PC literacy required.
• Excellent communicator, negotiator and great organizational skills.
• Strong knowledge of clinical documentation guidelines required.
• Must be able to work collaboratively and independently.
• Must be flexible with responsibilities in order to meet departmental needs.
• Must be able to demonstrate initiative and the ability to work in a fast-paced environment with proficiency in multi-tasking and prioritization.
• Experience in computerized hospital/health information management systems and software applications are required.

Skills

• Certification in Clinical Documentation Integrity (CCDS, CDIP) strongly desired.
• Certified in coding (CCS) preferred.
• Technical knowledge of ICD-10, DRG and APR assignment and prospective payment methodologies preferred.
• Detail oriented, have the ability to work independently, exercise good judgment and be resourceful.
• Ability to write reports independent of management review is a plus.
• Experience and/or knowledge of regulatory compliance issues facing the healthcare industry is also a plus.

Benefits

Note: Savista is required by state specific laws to include the salary range for this role when hiring a resident in applicable locations. The salary range for this role is from $85,000.00 to 90,000.00. However, specific compensation for the role will vary within the above range based on many factors including but not limited to geographic location, candidate experience, applicable certifications, and skills.

Pay

$85,000.00 to 90,000.00

Schedule

Not specified