Clinical Documentation Integrity Specialist

About the role

The Clinical Documentation Integrity Specialist is responsible for reviewing inpatient medical records to assess and procure accurate and complete documentation of the patients’ diagnosis and procedures. Reports to department leadership.

Responsibilities

• Reviews Inpatient Clinical Documentation, ensuring that physicians’ and clinicians’ documentation, accurately reflect the patient’s conditions, diagnoses, treatments, and interventions, resulting in accurate reimbursement.
• Reviews to ensure the clinical documentation, reflects the patient’s severity of illness, quality of care and resources used.
• Provides education to the physicians and ancillary providers regarding accurate, specific and compliant clinical documentation.
• Acts as a resource for other departments regarding the importance of clinical documentation integrity, and the need to clinically document following the Federal and State regulations.
• Performs all other duties as assigned.

Qualifications

• Required: Current Virginia state license as a Registered Nurse or Registered Nurse holding a valid Compact State license.
• Preferred: Certified Documentation Improvement Professional (CDIP) or Certified Clinical Documentation Specialist (CCDS) certification or must be credentialed through AHIMA or ACDIS, within two years of start.

Requirements

• Required: Registered Nurse - Professional knowledge of nursing theory and practice at a level normally acquired through the completion of an accredited School of Nursing.
• Preferred: BSN preferred. Pediatric and/or Clinical Documentation or Utilization Management preferred.

Skills

• Required: Experience with applying clinical criteria to a medical record review with a Clinical Documentation Integrity focus.
• Required: Knowledge of healthcare payment systems, specifically the MS-DRG, Tricare and APR-DRG reimbursement systems.
• Required: Ability to form positive and collaborative relationships, with Physicians, HIM colleagues, the Physician Advisor and other hospital staff.
• Required: Competent using Microsoft Office Suite, and different Electronic Medical Records.
• Required: Strong organizational, clinical critical thinking and analytical skills.
• Preferred: Technical and professional knowledge and skills for clinical operations of the service area, usually acquired through 3 - 5 years’ progressive Clinical/Supervisory experience in a practice setting.

Working Conditions

Normal office environment with little exposure to excessive noise, dust, temperature and the like.

Schedule

Monday-Friday 7:30 AM - 4:00 PM