Clinical Documentation Improvement Specialist II
About The Position
Capable clinician who has acquired broad experience in performing clinical reviews to facilitate the overall quality, completeness, timeliness, and accuracy of clinical documentation in the patient record to support the delivery of high-quality patient care, adherence to quality standards, the clinical coding process and appropriate hospital reimbursement. Serves as a resource and preceptor to colleagues assisting with peer reviews as required. Demonstrates development of analytical skills in identifying clinical documentation improvement opportunities upon medical record review. Recognizes the impact of CDI on compliance, quality patient outcomes and appropriate hospital reimbursement. Continues to recognize own performance limitations, but requires minimal assistance. Demonstrates a score of > 93% on the previous two quality assessments for the following KPIs: query compliance, PDx accuracy, and opportunity captured percentage. Implements quality CDI reviews independently. Manages time effectively. Functions in a developing leadership role. Orients staff as assigned in absence of designated preceptor. Demonstrates effective listening skills. Reduces barriers to facilitate communication. Utilizes effective conflict resolution skills. Has awareness of one's own values and how they affect interactions and relationships. May seek assistance to resolve complex issues. Respects and maintains confidential information. Accepts personal accountability for professional development and growth. Meets all CDS I Employee Commitments. Incumbent may work under close supervision following established routines or assigned work with limited employee latitude. Employee may work under general supervision and receives general guidance on work priority with substantial employee latitude. Employee may work independently under the general direction of their leader. Assist with the onboarding, training and development of New CDI staff. Be a resource for New and Junior CDI staff across Emory Healthcare. Assist in random quality reviews to ensure accurate and compliant chart review process, ensure consistent query compliance. Maintain dynamic communication with coders and CDI personnel to identify root cause of CDI-Coder final DRG mismatch and seek to resolve incongruence with appropriately assigned final DRG. Performs concurrent and retrospective reviews of the medical record (as needed), utilizing evidence-based knowledge, protocols and criteria. Conducts follow-up reviews of clinical documentation to ensure points of clarification have been recorded in the patient's chart. Be essential in supporting the Hospital Value-Based Purchasing (VBP) results, by reviewing documentation to ensure accuracy in the Patient Safety Indicators (PSI), Hospital Acquired Conditions (HAC), Present on Admission (POA) conditions, and Mortality reviews to avoid penalties associated with lack of proper documentation.
Requirements
- Graduate of an accredited school of nursing or Foreign medical graduate from an accredited medical school.
- Current licensure as a Registered Nurse in the state of Georgia.
- Minimum of 3 years recent clinical experience in an acute care setting (Critical Care, Medical/Surgical or Emergency department nursing preferred; or 2 years experience in a specialty area).
- Required Certification(s): CCDS by ACDIS or CDIP by AHIMA + 3 plus years of CDI experience.
- 5+ years in healthcare related field with strong clinical expertise and acumen.
Responsibilities
- Perform clinical reviews to facilitate overall quality, completeness, timeliness, and accuracy of clinical documentation.
- Serve as a resource and preceptor to colleagues.
- Identify clinical documentation improvement opportunities.
- Implement quality CDI reviews independently.
- Manage time effectively.
- Function in a developing leadership role.
- Orient staff as assigned.
- Demonstrate effective listening, communication, and conflict resolution skills.
- Accept personal accountability for professional development and growth.
- Assist with onboarding, training, and development of new CDI staff.
- Be a resource for new and junior CDI staff.
- Assist in random quality reviews.
- Maintain communication with coders and CDI personnel to resolve DRG mismatches.
- Perform concurrent and retrospective reviews of the medical record.
- Conduct follow-up reviews of clinical documentation.
- Support Hospital Value-Based Purchasing (VBP) results by reviewing documentation for accuracy in PSI, HAC, POA, and Mortality reviews.
Benefits
- Comprehensive health benefits that start day 1
- Student Loan Repayment Assistance & Reimbursement Programs
- Family-focused benefits
- Wellness incentives
- Ongoing mentorship and leadership programs
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
No Education Listed
