Clinical Documentation Improvement Specialist

About the Role

The Clinical Documentation Specialist reviews medical records to facilitate accurate and complete documentation that reflects clinical treatment, decisions, and diagnoses used for measuring and reporting hospital and physician outcomes. This role identifies additional documentation opportunities, places appropriate queries, and communicates with physicians, coders, and other healthcare team members to improve documentation. The position operates primarily in an approved remote home work environment.

Responsibilities

• Accurately reviews medical records concurrently for completeness in documentation of diagnostic and procedural information to ensure compliance with CMS, DOH regulatory, and financial requirements.
• Ensures documentation of diagnoses, procedures, co-morbid, and complication conditions reflects the medical record to support proper severity of illness, intensity of service, and risk of mortality classifications, as well as designated quality reviews (e.g., Patient Safety Indicator reviews).
• Prepares well-written and compliant queries to communicate with physicians and other providers regarding missing, incomplete, or clarifying information in the medical record.
• Works closely with coding staff to ensure documentation of discharge diagnoses and co-existing co-morbidities accurately reflects the patient’s clinical status and care.
• Interacts with and educates physicians (attendings, residents, and interns), nurse practitioners, and physician assistants on correct coding, regulatory compliance, and documentation improvements.
• Provides real-time intervention and education to address documentation deficiencies.
• Utilizes computer applications such as Epic EHR, 3M DRG, and MS Office, and maintains productivity expectations.
• Accurately records activity in CDI software tracking tools.
• Maintains expert knowledge of HIPAA PHI and all laws related to accessing protected health information.
• Demonstrates effective and independent work in a remote environment, troubleshooting systems issues in accordance with department policies.
• Reviews medical records for other identified regulatory requirements as applicable.
• Tracks and trends issues identified during concurrent reviews.
• Attends department meetings and actively contributes to the improvement and success of the department and hospital.
• Participates in continuing education, in-services, training sessions, and audioconferences related to coding and CDI to maintain skills and stay current with guideline changes.
• Demonstrates initiative, judgment, and creative problem-solving in job duties.
• Identifies process problems and suggests possible solutions.
• Performs duties in a professional, efficient, and positive manner.
• Completes other duties and assignments as necessary.

Requirements

• Bachelor of Science in Nursing, Health Information Management, or a related field. Certification, associate, or bachelor’s degree in another healthcare-related field with relevant experience may also be considered.
• Preferred certifications: CCDS, CDIP (CCDS required within 6 months of hire for eligible candidates).
• RN/BSN preferred; RHIA or RHIT with CCS, or MD/DO will also be considered.
• Maintenance of appropriate registration/certification, including tracking continuing education credits to maintain professional credentials if applicable.
• Working knowledge of Medicare reimbursement systems and coding structures preferred.
• 5 years of Critical Care/Emergency Medicine or 5 years of Medical-Surgical experience preferred.
• 2-3 years of Clinical Documentation Improvement experience or 5 years of coding experience preferred.
• MD/DO with two years of experience as a concurrent or retrospective coder or documentation specialist in an inpatient acute care facility using the U.S. IPPS system will be considered.
• Familiarity with computers and Microsoft Office applications.
• Ability to work independently with minimal supervision.
• Strong interpersonal, analytical, facilitation, and presentation skills.
• Ability to read and communicate effectively in English.

Additional Qualifications

• Lift and carry up to 25 lbs.
• Frequent sitting, standing, and keyboard use.
• *Patient care providers may be required to perform role-specific activities such as kneeling, bending, squatting, and performing CPR.

Schedule

Workday Day (United States of America)

Benefits

• Comprehensive benefits package for full-time and part-time colleagues, including medical (including prescription), supplemental insurance, dental, vision, life, and AD&D insurance.
• Short- and long-term disability coverage.
• Flexible spending accounts.
• Retirement plans.
• Tuition assistance and access to tuition discounts at Thomas Jefferson University after one year of full-time service or two years of part-time service.
• Voluntary benefits, including group insurance rates and discounts.
• All colleagues, including those working less than part-time (e.g., per diem, adjunct faculty, Jeff Temps), have access to medical (including prescription) insurance.