Clinical Documentation Improvement

To be part of our organization, every employee should understand and share in the YNHHS Vision, support our Mission, and live our Values. These values—integrity, patient-centered, respect, accountability, and compassion—must guide what we do, as individuals and professionals, every day.

Responsibilities

• Reviews medical records of hospitalized patients to identify the most appropriate principal diagnosis, secondary diagnoses, procedures, and assign a working DRG.
• Performs initial reviews, concurrent reviews, and retrospective reviews to ensure the DRG accurately reflects the principal diagnosis and all comorbid conditions after study.
• Independently evaluates record for missing diagnoses pre- and post-discharge.
• Completes reviews to ensure working DRG and all comorbid conditions are documented by the providers to the greatest specificity.
• Collaborates with the coding staff concurrently and retrospectively to ensure the chart has all the necessary documentation to support the most accurate coding.
• Educates CDS staff on clinical documentation and coding guidelines.
• Develops and conducts ongoing Clinical Documentation Management program (CDMP) education for new staff including new clinical documentation specialists, coders, physicians, residents, nursing, and allied health professionals.
• Develops and supports strong professional relationships with CDS, Coding staff, Physician leadership, and Clinicians across the system.
• Utilizes a compliant query process per guidelines and policy when sending all queries; follows each query through to closure including complete documentation of ongoing follow-up activities and communication.
• Works collaboratively with all licensed independent providers to ensure positive program outcomes.
• Provides CDI training to providers one-on-one, during staff meetings, or department meetings.
• Assists in other monitoring activities, special department projects, or other needs as determined by the department management.
• Provides ongoing CDS team learning opportunities by sharing professional knowledge.
• Orients new hires to YNHHS CDI program.
• Provides feedback on current process and coding knowledge.
• Maintains integrity and compliance in all chart reviews, CDI documentation, and queries at all times.
• Follows a process designed to allow effective risk adjustment and reimbursement.
• Maintains an audit score > 95%.
• Supports and implements quality measures as identified by department management.
• Identifies and implements opportunities for performance improvement.

Requirements

• Registered Nurse with active RN license required.
• BSN preferred.
• Certified Clinical Documentation Specialist (CCDS) through ACDIS or Certified Documentation Integrity Specialist Practitioner (CDIP) through AHIMA and/or Certified Coding Specialist (CCS) through AHIMA preferred.
• Minimum of one (1) year of recent CDI experience meets requirement of Clinical Documentation Associate and submits completed CDI I Leadership Portfolio.
• Clinical expertise required.
• CDI experience for a minimum of one (1) year is required.
• RN license required; CCDS, CCS preferred.

Skills

• Excellent communication, negotiation, and organizational skills.
• Adaptability to a wide variety of interpersonal encounters with the entire hospital team.
• Comprehensive understanding in use of medical records to extract data.
• Willingness to learn clinical and coding concepts.
• Exhibits working knowledge of third-party and prospective payment systems.
• Computer literacy required; ability to work on various software platforms.
• Capable of working collaboratively and independently.
• Displays flexibility with responsibilities to meet departmental needs.
• Must have keen eye for detail.

Physical Demand

Ability to communicate clearly and confidently with providers regarding the program's goals and documentation issues using email, in-person communication, telephone, and other written and electronic forms of communication.