Clinical Documentation Specialist I

Job Summary

The Clinical Documentation Specialist (CDI) I, reports to the Market Clinical Documentation Specialist Manager. Under limited direction works collaboratively with medical, nursing and ancillary staff, and case managers and coders to improve the overall accuracy, quality and completeness of clinical documentation in accordance to clinical documentation guidelines and established policies/procedures.

Responsibilities

• Facilitates appropriate clinical documentation to support appropriate diagnosis coding and to ensure the level of service rendered to all patients is recorded.
• Collaborates with HIM coding staff to promote complete and accurate clinical documentation and correct negative trends.
• Communicates with physicians, nurse practitioners, case managers, coders and other members of the care team to facilitate comprehensive medical record documentation to reflect treatment, decision-making and medical documentation.
• Sets a working MS/APR-DRG and severity level using coding rules and guidelines with follow up reviews as required by LOS standards.
• Analyzes clinical information to identify areas within the chart for potential gaps in physician documentation.
• Queries physicians on a concurrent basis. Works with physicians to clarify documentation in the medical record.
• Formulates credible clinical documentation clarifications to improve clinical documentation of principal diagnosis, co-morbidities, present on admission (POA), quality core measures, and patient safety indicators (PSI).
• Conducts post discharge reviews for comparative analysis of CDI Specialist and HIM MS/APR-DRG and severity level assignment.
• Reviews clinical issues with the coding staff to assign a working DRG.
• Develops and conducts ongoing education for new staff, including new CDI Specialists, physicians and nursing.
• Utilizes software systems (including APR-DRG encoder) to collect, track, and report outcomes.
• Requires proficiency in abstracting and data entry into all databases used for clinical documentation.
• Maintains integrity of data collection.
• Participates in ongoing education of staff.
• Develops educational material and tools relative to documentation improvement practices for individual practitioners and groups of clinicians presented as handouts, PowerPoint, etc.

Qualifications

• Required: Graduate from an accredited School of Nursing with RN or LPN, BSN or Graduate from an accredited School of Medicine with MD or MBBS (either foreign or domestic), And have minimum of 1-year experience working as a CDI in an acute care hospital.
• PREFERRED: Graduate from an accredited Health Informatics program for clinical Documentation 1 – 2 -years’ experience or more working as a CDI in an acute care hospital 3 - years’ experience or more in a clinical setting with patient care.
• REQUIRED CERTIFICATIONS/LICENSURE: Either RN, or LPN with an active license Or MD, or MBBS Preferred: BSN CDI related certificate (RHIA, RHIT, CCS, CDIP, CCDS) USMLE Certificate Required: KNOWLEDGE, SKILLS, ABILITIES: Analytical ability and comprehensive knowledge base to gather and interpret clinical documentation data, to identify discrepancies, problems or issues, and to determine methods for ensuring compliance with clinical documentation policies and procedures. Ability to analyze data for patterns and trends. Strong critical thinking skills and ability to integrate knowledge. Excellent observation, communication and decision-making abilities. Strong presentation skills in order to articulate the program to physician and other health care professionals in order to educate and teach clinical documentation requirements and educate all members of the care team. Ability to prioritize work, focus on completion of tasks and meet deadlines through strong organizational skills. cope with stressful situations, manage multiple and sometimes conflicting priorities simultaneously. Demonstrates motivation and can work as a focused, self-directed individual. High-level communication skills both verbal and written. Ability to collaborate and use assertive interpersonal skills to discuss clinical documentation issues and work effectively with all levels of internal personnel such as coders, physicians, nursing and allied health professionals. Demonstrated team player skills and encourage a spirit of cooperation among CDI team, clinicians, coders, physicians, etc., and direct others toward objectives that contribute to the success of the program. Knowledge of clinical documentation guidelines, policies and procedures, and the requirements of compliant query and communication with clinicians. Strong computer skills and knowledge of Email, Microsoft Word, Microsoft Excel or other software packages including database and spreadsheet programs. Preferred: Demonstrated leadership skills Have experience working with Iodine, 3M encoder, Artifact or Cerner-PowerChart Skilled in conflict resolution