Clinical Document Integrity Specialist

Cheyenne Regional Medical Center • Cheyenne, WY

5d • Onsite

About The Position

The Clinical Document Integrity Specialist (CDIS) is a key representative to and for the organization's clinical and coding documentation improvement initiatives. The CDIS is responsible for improving the overall quality and completeness of provider documentation of diagnoses and procedures using terminology integral to HIPAA related transaction sets. The CDIS facilitates clinical documentation improvement through extensive daily interaction with physicians, caregivers, case management and coding staff to achieve timely, accurate, and complete documentation. Educates all members of the patient care team on clinical documentation improvement.

Requirements

• Wyoming Registered Nurse License or enhanced Nurse Licensure (eNLC)
• One (1) or more years of RN experience in a clinical setting
• One year: Certified Coding Specialist (CCS) certification issued by American Health Information Management Association (AHIMA) or Certified Professional Coder (CPC) certification issued by American Academy of Professional Coders (AAPC) within one year from start date
• Strong knowledge of clinical practices and patient population to collaborate with all members of the care team
• Strong knowledge of disease definitions and natural history
• Ability to assess/interpret data reflecting patient clinical status
• Ability to work with limited supervision
• Professional verbal, written, and interpersonal communication skills
• Ability to use technology and software supporting daily activities
• Ability to provide occasional evening, weekend, and holiday coverage.
• Ability to independently perform critical analysis
• Ability to resolve complaints/problems within a reasonable time period
• Ability to function as an integral member of a multi-disciplinary team

Nice To Haves

• Clinical Document Integrity (CDI) experience
• Epic experience
• Two (2) or more years of coding experience

Responsibilities

• Reviews medical records upon admission, concurrently, and at discharge to identify documentation opportunities and ensures all pertinent conditions are documented timely to reflect severity of illness and acuity of care.
• Develops training materials and educates physicians and caregivers on the importance of complete and accurate clinical documentation as it relates to patient acuity, severity of illness, physician profiling/scorecards/core measures, and regulatory reimbursement guidelines.
• Participates in meetings and attends rounds with physicians/providers for patients on assigned services. Reviews and discusses documentation on patient records with physician/provider during or immediately following rounds.
• Communicates and seeks clarifications from providers for questions related to principal diagnoses, comorbid conditions, complications, and/or procedures based on industry standards, hospital policy, or clinical indicators. Conducts reviews to ensure clarifications have been recorded in the patient’s medical record timely and accurately. Informs management of unresolved issues.
• Establishes the working DRG assignment collaborating with coding liaison as necessary.
• Ensures timely data entry and closure of cases in electronic database.
• Responsible for the identification of core measures related to the quality initiatives in the organization.
• Collects data to assess improvements in quality of clinical documentation and success of initiatives. Identifies additional opportunities for process improvement by preparing administrative and clinical statistical reports along with promoting and participating in LEAN practices and strategies.
• Performs retrospective reviews of records for identification of missing/clarification information.

Benefits

• Employer Sponsored Medical, Dental, and Vision Plans
• 403(b) and 457(b) retirement options with 4% employer match
• Life Insurance
• Short Term and Long-Term Disability Insurance
• Employer Sponsored Wellness Program
• Employee Assistance Program
• 21 PTO days per year (increases with tenure)
• Tuition Reimbursement Program
• Dedicated Loan Forgiveness Advisory Service

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: No Education Listed