Clinical Documentation Improvement Specialist (REMOTE)-5
Current employees and students: internal applicants should use the Workday job search and application process.
About the Role
The Clinical Documentation Improvement Specialist (CDIS) is a nurse or other clinically qualified individual responsible for concurrent review of inpatient medical records to identify opportunities for improving the quality of medical record documentation. This includes identifying cases where diagnoses and procedures are either absent, not stated in appropriate terminology, or are not appropriately recorded. The CDIS confers with caregivers to clarify additional documentation needs, aiming to achieve a complete medical record by patient discharge. The goal is to ensure quality documentation that accurately reflects patients’ diagnoses, treatments, and severity of illness, while facilitating and enhancing the coding and DRG assignment process.
This position supports initiatives to improve documentation quality across the Ohio State University Health System, with a focus on enhancing documentation to support coding processes. This improvement ultimately enhances the organization’s performance on quality measures and the Case Mix Index (CMI), which is critical to the financial health of the organization. The CDIS adheres to The Joint Commission (TJC), Medicare, and third-party payer documentation guidelines, as well as the official guidelines for assigning ICD-10-CM diagnosis and procedure codes. The role involves assisting attending physicians and other healthcare providers in the patient care documentation process.
Requirements
- Bachelor's Degree in Nursing
- Registered Nurse (RN) licensure
- 2 years of relevant experience required (2-4 years preferred)
Final candidates are subject to a background check. A drug screen or physical may be required during the post-offer process.