Clinical Document Integrity Specialist

Cheyenne Regional Medical Center • Cheyenne, WY

13d

About The Position

The Clinical Document Integrity Specialist (CDIS) represents and supports the organization’s clinical and coding documentation improvement initiatives. The role improves the quality and completeness of provider documentation for diagnoses and procedures using terminology integral to HIPAA-related transaction sets. Through daily interaction with physicians, caregivers, case management, and coding staff, the specialist supports timely, accurate, and complete documentation and educates patient-care team members about clinical documentation improvement.

Requirements

• Wyoming Registered Nurse License or enhanced Nurse Licensure (eNLC).
• At least one year of RN experience in a clinical setting.
• Obtain Certified Coding Specialist (CCS) certification issued by AHIMA or Certified Professional Coder (CPC) certification issued by AAPC within one year from the start date.
• Strong knowledge of clinical practices and the patient population to collaborate with members of the care team.
• Strong knowledge of disease definitions and natural history.
• Ability to assess and 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 that support daily activities.
• Ability to provide occasional evening, weekend, and holiday coverage.
• Ability to independently perform critical analysis.
• Ability to resolve complaints and problems within a reasonable time period.
• Ability to function as an integral member of a multidisciplinary team.

Nice To Haves

• Clinical Document Integrity (CDI) experience.
• Epic experience.
• At least two years of coding experience.

Responsibilities

• Review medical records at admission, concurrently, and at discharge to identify documentation opportunities and ensure pertinent conditions are documented in a timely manner to reflect severity of illness and acuity of care.
• Develop training materials and educate physicians and caregivers about complete and accurate clinical documentation, including its relationship to patient acuity, severity of illness, physician profiling and scorecards, core measures, and regulatory reimbursement guidelines.
• Participate in meetings and attend rounds with physicians and providers for patients on assigned services; review and discuss patient-record documentation during or immediately after rounds.
• Communicate with providers and seek clarification regarding principal diagnoses, comorbid conditions, complications, and procedures based on industry standards, hospital policy, or clinical indicators.
• Review records to ensure provider clarifications are recorded timely and accurately, and inform management of unresolved issues.
• Establish the working DRG assignment, collaborating with the coding liaison as needed.
• Enter data and close cases in the electronic database in a timely manner.
• Identify core measures related to the organization’s quality initiatives.
• Collect data to assess clinical documentation quality improvements and the success of initiatives.
• Identify process-improvement opportunities by preparing administrative and clinical statistical reports and promoting and participating in LEAN practices and strategies.
• Perform retrospective record reviews to identify missing information or information requiring clarification.

Benefits

• Employer-sponsored medical, dental, and vision plans.
• 403(b) and 457(b) retirement options with a 4% employer match.
• Life insurance.
• Short-term and long-term disability insurance.
• Employer-sponsored wellness program.
• Employee assistance program.
• 21 PTO days per year, increasing with tenure.
• Tuition reimbursement program.
• Dedicated loan forgiveness advisory service.

What This Job Offers

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