Clinical Documentation Improvement Specialist (REMOTE)-5

The Ohio State University

5d • Remote

About The Position

The Clinical Documentation Improvement Specialist (CDIS) is a nurse or other clinically qualified individual who is responsible for concurrent review of inpatient medical records to identify opportunities for improving the quality of medical record documentation. Opportunities include identification of cases where diagnoses and procedures are either absent, not stated in appropriate terminology, or are not appropriately recorded. The CDIS will confer with the appropriate caregiver on the additional documentation that may be required. The Documentation Specialist’s goal is to achieve a complete medical record by the time of patient discharge in order to ensure quality documentation that reflect the patients’ diagnoses, treatments, and severity of illness, and to facilitate and enhance the coding and DRG assignment process.

This position supports initiatives to improve the quality of documentation by all caregivers within the Ohio State University Health System with specific emphasis on improving documentation to support the coding process which ultimately improves the organization’s performance on quality measures and on the Case Mix Index (CMI) which is critical to the financial health of the organization. The CDIS follows The Joint Commission (TJC), Medicare and third party payer documentation guidelines and the official guidelines for assigning ICD- 10-CM diagnosis and procedure codes in efforts to continually improve the quality of medical record documentation. The CDIS provides assistance to the attending physician and other health care providers in the patient care documentation process.

Requirements

• Bachelor's Degree in Nursing.
• Registered Nurse.
• 2 years of relevant experience required.

Nice To Haves

• 2-4 years of relevant experience preferred.

Responsibilities

• Concurrent review of inpatient medical records to identify opportunities for improving the quality of medical record documentation.
• Identify cases where diagnoses and procedures are absent, not stated in appropriate terminology, or not appropriately recorded.
• Confer with the appropriate caregiver on additional documentation that may be required.
• Achieve a complete medical record by the time of patient discharge.
• Ensure quality documentation that reflects patients’ diagnoses, treatments, and severity of illness.
• Facilitate and enhance the coding and DRG assignment process.
• Support initiatives to improve documentation quality within the Ohio State University Health System.
• Improve documentation to support the coding process, ultimately improving the organization’s performance on quality measures and Case Mix Index (CMI).
• Follow The Joint Commission (TJC), Medicare and third party payer documentation guidelines and official guidelines for assigning ICD- 10-CM diagnosis and procedure codes.
• Provide assistance to the attending physician and other health care providers in the patient care documentation process.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level