Clinical Documentation Improvement Specialist

Responsibilities

• Ensure accurate, complete, and compliant documentation in the medical record for proper MS DRG and APR DRG assignment.
• Capture severity-of-illness (SOI) and risk-of-mortality (ROM) levels and reflect the quality of care provided based on CMS rules and regulations.
• Collaborate with MHS Medical Staff, HIM Coders, quality improvement professionals, and other healthcare team members to achieve optimal outcomes.
• Stay updated on industry changes impacting the role.
• Educate members of the patient care team on clinical documentation guidelines and service-specific requirements, both formally and informally.
• Uphold the mission, vision, values, and customer service standards of The MetroHealth System.

Qualifications

• Required: Possesses one of the following: RN licensure (BSN required if hired after April 2023), RHIA, RHIT.
• Five years of experience in an inpatient acute care environment as a clinician or hospital inpatient coder.
• Demonstrated knowledge and proficiency in using clinical information systems and office automation.
• Strong understanding of pathophysiology and disease management.
• Broad-based clinical background.
• Excellent verbal and written communication skills and critical thinking skills.
• Demonstrated ability to work effectively with medical providers and handle multiple tasks and educational activities.
• Ability to work independently and be self-directed.
• Ability to travel to various clinical areas as assigned.
• Ability to interact effectively with a wide range of cultural, ethnic, racial, and socioeconomic backgrounds.
• PREFERRED: Active CCDS from ACDIS or active CDIP from AHIMA.
• Graduate degree in related field.
• One to three years inpatient clinical documentation improvement experience in a tertiary academic healthcare system.
• Working knowledge of Medicare reimbursement and ICD-10 coding structures.
• Demonstrated knowledge of the EPIC electronic medical record and 3M 360 Encompass systems.
• Use of Microsoft Office software such as Word, Excel, and PowerPoint.