Clinical Documentation Improvement Specialist

Job Requisition ID: R0004840

About the Role

To support and review the inpatient medical record in order to facilitate improvement in overall quality, completeness, clinical severity, and accuracy of inpatient clinical documentation for DRG-based or APR-based payor populations for specific departments or areas. To obtain and promote appropriate clinical documentation through extensive interaction with physicians and other members of the healthcare team.

Responsibilities

• Reviews inpatient medical record within 24-48 hours of admission to ensure accuracy and completeness and identifies documentation opportunities that reflect severity of illness, acuity, and resource consumption.
• Assigns a working DRG based on principal diagnosis and procedure.
• Identifies comorbidities and complications, present-on-admission diagnoses, and quality issues; reports quality issues to the responsible party.
• Proficient in complex decision-making with a high degree of accuracy.
• Reviews and enters information in both Epic and 3M 360 as required; ensures accuracy by reviewing inpatient charts every 24-48 hours as follow-up.
• Identifies documentation that reflects severity, acuity, quality issues, and resource consumption; updates findings in 3M 360 software.
• Communicates with physicians and other patient care providers, both verbally and in writing, regarding documentation opportunities for improvement.
• Assists in the development and presentation of educational materials regarding documentation to CDI staff, providers, and other healthcare team members.
• Applies effective assessment skills to identify clinical indicators for diagnoses.
• Integrates new or current techniques (procedures, surgeries, CDI issues, documentation improvement opportunities) related to planning, implementing, and evaluating patient care documentation.
• Provides timely internal/external customer service in a cooperative, professional, and respectful manner.
• Formulates complex queries to obtain clarifications of conflicting, ambiguous, or non-specific documentation via verbal or written compliant queries.
• Determines when to escalate issues to senior team members, providers, or administrators.
• Collaborates with CDI Specialist III to review individual problematic cases and/or educational needs.
• Demonstrates a highly developed understanding of risk management and/or quality program (PSI/HAC) cases; discusses with senior team members as appropriate.
• Maintains current ACDIS Certification status; participates in CDI-related education activities to maintain certifications and licensure.
• Conducts independent research to promote knowledge of clinical topics, coding guidelines, regulatory policies, trends, and healthcare economics.
• Contributes to a positive work environment and performs other duties as assigned or directed to enhance overall organizational efforts.
• Maintains UMMC network security of personal health information; ensures confidential material is not accessed or viewed by unauthorized persons during working hours.
• Sets aside a dedicated workspace at home; shreds all information containing PHI (personal health information).
• Performs any other assigned duties, as management retains the right to add or change duties at any time.

Requirements

• Valid RN license.
• CCDS (Certified Clinical Documentation Specialist) preferred upon hire but required within three years of hire.
• Five (5) years of clinical nursing in Acute Care, Utilization Review, Case Management, Quality Management, and/or Hospital-based Clinical Documentation experience (hospital-based Clinical Documentation experience preferred).

Skills

• Knowledge of evidence-based clinical guidelines across a wide variety of conditions and age groups.
• Knowledge of resource/utilization management.
• Skill in the use of personal computers and related software applications.
• Ability to manage multiple priorities under time constraints; analyze and solve problems.
• Understanding of cost and quality issues.
• Excellent verbal and written communication skills; interpersonal skills to interact with a wide range of constituencies.
• Decision-making skills; demonstrated ability to perform and maintain working relationships within the department and across business units.
• Healthcare revenue cycle experience preferred.
• Proficient knowledge and experience in Microsoft Office Suite (Excel, PowerPoint, Word, and Outlook).

Environmental and Physical Demands

• No exposure to unpleasant or disagreeable physical environment (e.g., high noise levels, extreme heat/cold).
• No handling or working with potentially dangerous equipment.
• Occasional working hours beyond regularly scheduled hours; occasional travel to offsite locations.
• Frequent activities subject to significant volume changes of a seasonal/clinical nature.
• Constant work produced is subject to precise measures of quantity and quality.
• Occasional bending; occasional lifting/carrying up to 10 pounds; occasional lifting/carrying up to 25 pounds.
• No lifting/carrying of 50 pounds or more.
• Occasional climbing; no crawling; occasional crouching/stooping; occasional driving; no kneeling; occasional pushing/pulling.
• Frequent reaching, sitting, standing, and walking; occasional twisting.

Schedule

• Full time (100% FTE).
• Day shift.

Benefits

• Eligible for benefits.