Clinical Documentation Improvement Specialist - Clinical Doc Integrity - FT Days

Sky Lakes Medical Center•Klamath Falls, OR

38d•Onsite

About The Position

This role focuses on improving clinical documentation within the hospital setting. The specialist will review patient records to identify opportunities for enhancing the accuracy and specificity of physician documentation. This is crucial for appropriate assignment of MS-DRG, capturing co-morbidities/complications, and aligning with payer system requirements. The position involves effective communication with physicians to obtain necessary clarifications and collaboration with Health Information Management (HIM) staff. The specialist will also monitor the CDI process to ensure program goals are met and participate in educational initiatives.

Requirements

Minimum of five years of recent hospital experience as a Registered Nurse (RN), four years of recent clinical experience for Nurse Practitioners (NP), or Physician Assistants (PA).
Strong organizational and analytical skills.
Dependable, with a proven ability to manage their time and responsibilities independently and efficiently with minimal supervision.
Professionalism in appearance and conduct.
Capable of handling multiple priorities while consistently meeting productivity targets.
Proficiency in computer use, including familiarity with electronic health records and Windows-based software programs such as Microsoft Office.
Willing and able to understand and support Clinical Documentation Management Program (CDMP) documentation strategies upon completion of relevant training.
Current Oregon RN, NP, LPN, or PA license.

Responsibilities

Identifies records for review based on prioritization by length of stay, diagnosis, and other defined CDI strategies.
Reviews records and accurately identifies opportunities for improvement in physician documentation related to appropriate assignment of MS-DRG, and capturing major co-morbidities/complications (MCCs) and co-morbidities/complications (CC’s), as appropriate to the payer system.
Identifies opportunities for increasing specificity and accuracy of documentation.
Formulates clinically credible documentation clarifications.
Effectively communicates with physicians to obtain clarifications in a timely and compliant manner.
Follows up as needed to ensure a high rate of query responses.
Monitors the CDI process and personal effectiveness to ensure CDS activities are on track to meet the goals of the program.
Consults with Inpatient CDI Manager as needed to optimize process related to specific high-volume high-risk diagnoses.
Communicates with HIM staff and resolves discrepancies in a collaborative manner.
Participates in identification of opportunities for CDI intervention via query or physician education.
Helps ensure the confidentiality and security of patient information accessed through his/her department.
Performs other duties as assigned.