CDI Specialist

Houston Methodist•Houston, TX

About The Position

Improves the overall quality, completeness and accuracy of clinical documentation by performing open record reviews using clinical documentation guidelines. Supports the accuracy and completeness of clinical information used for measuring and reporting physician and medical outcomes. Seeks additional information regarding clinical condition from appropriate clinical personnel and follows up as necessary. Tracks responses and trends completion of DRG/Documentation worksheets as pertinent to scope of department. Conducts follow-up reviews of clinical documentation to ensure points of clarification have been recorded in the patient’s chart. Demonstrates knowledge of DRG payor issues, optimization strategies, clinical documentation requirements and referral policies and procedures. Requests clarification and/or correction from physicians for unclear diagnoses, complications, procedures, and clinical information. Helps identify appropriate ICD10 codes for diagnoses or procedures related to projects or studies being conducted as needed. Promotes clarification to clinical documentation to ensure that appropriate reimbursement is received for the level of service rendered to all patients. Identifies diagnoses and procedures performed and comorbidities and complications. Impacts discharges by updating the DRG worksheet to reflect any changes in status, procedures/treatments, conferring with physician to finalize diagnosis as necessary. Educates all internal customers on clinical documentation opportunities, coding, and reimbursement issues, as well as performance improvement methodologies

Requirements

Associate’s or bachelor’s degree in nursing
Five years of recent clinical experience caring for adults in an acute care hospital setting
RN - Registered Nurse - Texas State Licensure - Texas Board of Nursing_PSV Compact Licensure – Must obtain permanent Texas license within 60 days (if establishing Texas residency)
Demonstrates the skills and competencies necessary to safely perform the assigned job, determined through on-going skills, competency assessments, and performance evaluations
Sufficient proficiency in speaking, reading, and writing the English language necessary to perform the essential functions of this job, especially with regard to activities impacting patient or employee safety or security
Ability to effectively communicate with patients, physicians, family members and co-workers in a manner consistent with a customer service focus and application of positive language principles
Demonstrates knowledge of DRG payor issues, appropriate DRG assignment alternatives, clinical documentation requirements, and referral policies and procedures
Demonstrates accountability and professional development
Requires excellent observation skills, analytical thinking, problem solving, plus good verbal and written communication
Regular significant contacts with other personnel throughout the institution (including but not limited to – physicians and their staff, mid-level providers, mid-level staff, coders, Case Managers). Contacts may be in person, by telephone, or through correspondence. Requires assertiveness while being even tempered, with a pleasing personality and the ability to communicate easily with others.

Nice To Haves

Coding and utilization review experience preferred
CCDS - Clinical Documentation Specialists (ACDIS) or
CDIP - Certified Documentation Integrity Practitioner (AHIMA) or
CCS - Certified Coding Specialist (AHIMA)

Responsibilities

Improves the overall quality, completeness and accuracy of clinical documentation by performing open record reviews using clinical documentation guidelines.
Supports the accuracy and completeness of clinical information used for measuring and reporting physician and medical outcomes.
Seeks additional information regarding clinical condition from appropriate clinical personnel and follows up as necessary.
Tracks responses and trends completion of DRG/Documentation worksheets as pertinent to scope of department.
Conducts follow-up reviews of clinical documentation to ensure points of clarification have been recorded in the patient’s chart.
Demonstrates knowledge of DRG payor issues, optimization strategies, clinical documentation requirements and referral policies and procedures.
Requests clarification and/or correction from physicians for unclear diagnoses, complications, procedures, and clinical information.
Helps identify appropriate ICD10 codes for diagnoses or procedures related to projects or studies being conducted as needed.
Promotes clarification to clinical documentation to ensure that appropriate reimbursement is received for the level of service rendered to all patients.
Identifies diagnoses and procedures performed and comorbidities and complications.
Impacts discharges by updating the DRG worksheet to reflect any changes in status, procedures/treatments, conferring with physician to finalize diagnosis as necessary.
Educates all internal customers on clinical documentation opportunities, coding, and reimbursement issues, as well as performance improvement methodologies