Clinical Documentation Improvement Specialist II - Full Time

Description of Position

The Clinical Documentation Improvement Specialist II is an experienced, certified CDI with a broad clinical knowledge base and understanding of DRG documentation requirements who works under the supervision of the CDI Director and in collaboration with the CDI Educator.

Responsibilities include secondary clinical chart reviews, resolution of DRG discrepancies, and improvement of capture of additional comorbid conditions to include HAC's and focused PSI diagnoses.

The Clinical Documentation Improvement Specialist II will conduct concurrent secondary and retrospective medical record review for defined patient populations to identify opportunities to improve accuracy of documentation; collaborating with Quality team, Case Managers and Coding department to assure documentation is clinically appropriate, accurately reflects the severity of illness for the patient, and is reflective of current CMS standards.

Supervision

Reports directly to the Director of CDI

Responsibilities and Duties

• Completes concurrent secondary reviews of targeted patient populations to identify missed opportunities and accurate selection of principal diagnosis.
• Advanced clinical expertise and extensive knowledge of complex disease processes with a broad clinical experience in an inpatient setting required.
• Acts as liaison between the Coding Department and the Clinical Documentation Specialist to reconcile discrepancies in DRG assignment.
• Collaborates with CDI educator when specified educational needs are identified.
• Documents and tracks secondary review data. Shares this information with CDI Director and CDI Educator
• Analyzes and interprets clinical data to identify gaps, inconsistencies, and/or opportunities for improvement in the clinical documentation and appropriately query the provider using a concurrent or retrospective query process. Follow up to ensure queries are answered.
• Sets the appropriate DRG, MCCs and CCs to each record reviewed.
• Collaborates with other clinical disciplines and members of the coding department to ensure high quality clinical documentation and efficient, timely coding of the medical record.
• Collaborates with Coding Department when discrepancies in the medical record are identified and reviews medical record to provide clinical feedback for accurate coding of procedural codes, ICD-CM diagnosis or DRG.
• Develops collaborative relationships and promotes teamwork with coworkers and other departments.
• Organizes and performs work responsibilities effectively and efficiently.
• Maintains strict patient confidentiality, adhering to HIPPA guidelines.
• Demonstrates standards of performance (ownership, teamwork, communication, compassion) that support patient satisfaction and principles of service excellence.
• Performs other duties as assigned.

Certification, Registration, or Licensure Required

• Doctor of Medicine (MD), Doctor of Osteopathy (DO), Foreign Medical Graduate (FMG), Physician Assistant (PA), or Registered Nurse/BSN
• RHIA, RHIT, or related clinical allied health degree
• Licensure / Certifications: CCS, CCDS, or CDIP required

Experience

• Minimum of 3 years experience as a Clinical Documentation Specialist required.

Physical Demands/Work Environment

• Work requires a variety of physical activities, including moving about within and outside of all hospital properties for long periods of time.
• Must be able to respond quickly and effectively to emergency and non-emergent situations.
• May be required to assist in controlling disorderly conduct or combative patients.
• Must be able to exchange accurate information with patient, family, peers and medical personnel.
• Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions

About the Role

We place a high value on our employees. We attract talented people who thrive in a team environment, recognize the importance of accountability and strive to exceed our patient's expectations.

Benefits

We offer our employees medical, dental & vision insurance, flexible spending accounts, retirement options, paid time off, tuition assistance & much more to attract and retain employees.

Pay

N/A

Schedule

N/A