Clinical Documentation Imp Specialist

DRISCOLL HEALTH PLAN

1d • Remote

About The Position

This is a full-time remote Clinical Documentation Improvement Specialist position at Driscoll Children’s Hospital, a 191-bed tertiary care center in South Texas. The role involves reviewing complex pediatric patient documentation to ensure accuracy in accordance with all current payer initiatives and development in acute and chronic disease states. The specialist must possess a high level of clinical proficiency, understanding specialized disciplines like anatomy, physiology, pathophysiology, and pharmacology, along with knowledge of official medical coding guidelines, CMS, and private payer regulations related to the Inpatient Prospective Payment System. Key responsibilities include analyzing and interpreting medical record documentation, formulating appropriate physician queries, and assisting in benchmarking clinical documentation program performance. The position requires sufficient knowledge of clinical documentation, ICD coding/reporting requirements, APR-DRG assignment, and clinical conditions impacting severity of illness, risk of mortality, and data quality. The specialist facilitates complete and accurate documentation and coding of inpatient medical records, serves as a resource for HIM coders and physicians, and educates the patient care team on documentation guidelines. Collaboration with interdisciplinary teams, including physicians, nurse practitioners, PAs, Quality, Case Management, Risk Management, Health Information Management/Coding, Decision Support, and product vendors, is essential. The company, Driscoll Health System, is a non-profit, community-based organization serving 31 South Texas counties, committed to core values of Compassion, Advocacy, Respect, Excellence, and Stewardship.

Requirements

• RHIA, RHIT, CCS, CDIP, or CCDS certification with a minimum of two years ICD hospital-based coding experience, OR clinical candidates credentialed as RN, LVN or BSN with a strong clinical background and a minimum of three years clinical experience in Pediatrics, Med-Surg, ICU, or Surgery.
• RHIA, RHIT, or CCS certification required or eligible – to be achieved within 1 year of employment.
• CDIP or CCDS certification required or eligible – to be achieved within 1 year of employment.
• Proficiency in the use of Microsoft applications (e.g. Word, Excel, PowerPoint), Epic, and 3M CRS and 3M CDI 360 Encompass.

Responsibilities

• Maintains utmost level of patient confidentiality.
• Adheres to hospital policies and procedures.
• Demonstrates business practices and personal actions that are ethical and adhere to corporate compliance and integrity guidelines.
• Completes initial reviews timely in order to promptly identify potential documentation improvement opportunities.
• Conducts follow-up reviews of patients as scheduled to support and assign a working or final APR- DRG.
• Queries physicians regarding missing, unclear, or conflicting health record documentation.
• Educates physicians and key healthcare providers regarding clinical documentation improvement and the need for accurate and complete documentation in the health record.
• Collaborates with CDI Physician Champion, case managers, nursing staff, and other ancillary staff regarding interaction with physicians on documentation and to resolve physician queries prior to patient discharge.
• Participates in the analysis and trending of statistical data for specified patient populations to identify documentation improvement opportunities.
• Assists with preparation and presentation of clinical documentation monitoring/trending reports for review.
• Partners with the coding professionals to ensure accuracy of diagnostic and procedural data and completeness of supporting documentation to assign ICD-9-CM and ICD-10-CM/PCS diagnosis and procedure codes to determine an accurate working and final APR-DRG, severity of illness, and/or risk of mortality.
• Assists in the appeal process resulting from third-party reviews.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Number of Employees: 101-250 employees