Clinical Documentation Specialist Apply
Clinical Documentation Improvement SpecialistResponsible for reviewing patient medical records throughout hospitalization to capture accurate representation of the severity of illness and facilitate proper coding. Validates that coding reflects medical necessity of services and facilitates appropriate coding which provides an accurate reflection and reporting of the severity of the patient's illness along with expected risk of mortality and complexity of care.Principal Accountabilities:Educates all internal customers, including physicians, nurses and other ancillary personnel, on clinical documentation opportunities, coding and reimbursement issues, as well as performance improvement methodologiesCreates job aids and queries in support of training initiativesEnsures the accuracy and completeness of clinical documentation used for measuring and reporting physician and hospital outcomes as well as appropriateness of treatment settingConducts follow-up reviews of clinical documentation to ensure points of clarification have been recorded in the patient's chartReviews clinical issues with coding staff, nurses and other healthcare professionals as appropriate to ensure appropriate inpatient technical diagnosis and procedural codingDiscusses cases with physicians/provides, including periodic meetings, rounding and/or attending medical staff meetingsInputs activities from concurrent reviews into CDI solution and ensures consistency of data capturedServes as a member of the facility CDI Team and Documentation Improvement Work Group, providing input relative to documentation improvement processes and resources, and updates corporate HIM on facility coding/documentation improvement effortsPerforms other relevant duties as assignedQualifications:Required:Associate's degree in Nursing.Bachelor of Science Nursing degree preferredRegistered licensed nurse (RN) requiredStrong clinical knowledge in respiratory failure, sepsis, CHF, ATN/CKD, and complex pneumonias requiredOne-two years experience as CDI Specialists preferred3M Coding and Reimbursement and/or 360 Encompass preferredWorking knowledge of ICD-10 preferredEpic experience preferred Preferred:Ability to achieve cognitive, organizational and emotional maturity to deal effectively with multiple tasks, stresses, deadlines, difficult situations and/or customers.Possesses interpersonal/communication skills necessary for effective, non-judgmental, and empathetic patient care and customer relations.Open to feedback and open to a changing environment, which requires flexibility in scheduling and department assignments.

