Clinical Documentation Improvement Specialist

Jefferson Health Plans • Philadelphia, PA

13h • Remote

About The Position

Under the direction of the CDI Manager, the Clinical Documentation Specialist reviews medical records to ensure accurate and complete documentation reflecting clinical treatment, decisions, and diagnoses. This role is crucial for measuring and reporting hospital and physician outcomes. The specialist identifies documentation improvement opportunities, places appropriate queries, and communicates with physicians, coders, and other health team members. The position primarily operates in an approved remote home work environment and requires independent work.

Requirements

• Bachelor of Science in Nursing
• Bachelor of Science in Health Information Management or related field.
• Certification, Associate or Bachelor in other healthcare related field with experience noted below.
• Working knowledge of Medicare reimbursement system and coding structures preferred.
• 5 years of Critical Care/Emergency medicine or 5 years of Medical Surgical Experience preferred
• 2-3 years Clinical Documentation Improvement experience or 5 years of Coding experience preferred.
• MD/DO with two years of experience as a concurrent or retrospective coder or documentation specialist in an inpatient acute care facility using the United States IPPS system will be considered.
• Familiarity with computers and Microsoft Office applications required.
• Ability to work independently with minimal supervision.
• Motivated, organized with excellent Interpersonal skills, analytical skills.
• Ability to read and communicate in the English Language

Nice To Haves

• CCDS, CDIP certification preferred
• RN/BSN preferred
• RHIA, or RHIT with CCS, MD or DO will be considered
• CCDS within 6 months of hire for eligible candidates
• Strong facilitation and presentation skills preferred.

Responsibilities

• Reviews medical records concurrently for completeness in documentation of diagnostic and procedural information for compliance to CMS, DOH regulatory, and financial requirements.
• Ensures documentation of diagnoses, procedures, co-morbid, and complication conditions support proper severity of illness, intensity of service, and risk of mortality classifications and designated quality reviews.
• Prepares well-written and compliant queries to communicate with physicians and other providers regarding missing, incomplete, or clarifying information needed in the medical record.
• Works closely with coding staff to ensure documentation of discharge diagnosis and co-existing co-morbidities completely reflect the patient’s clinical status and care.
• Interacts with and educates physicians (attending’s, residents and interns), nurse practitioners, and physician assistants, providing real-time intervention/education to promote correct coding, regulatory compliance, and correction of documentation deficiencies.
• Utilizes computer applications such as Epic EHR, 3M DRG, and MS Office.
• Maintains productivity expectations and accurately records activity in the CDI software tracking tool.
• Maintains expert working knowledge of HIPPA PHI and all laws relative to access PHI.
• Works effectively and independently in a remote home work environment and troubleshoots systems issues according to department policy.
• Reviews medical records for other identified regulatory requirements.
• Tracks and trends issues identified during concurrent reviews.
• Attends department meetings and actively contributes to the continued improvement and success of the department and the hospital.
• Attends continuing education meetings, in-services, and training sessions related to coding and CDI to maintain skills and stay abreast of coding guideline changes and best practice CDI processes.
• Demonstrates initiative, judgment, and creative ability in job performance.
• Identifies process problems and suggests possible solutions.
• Functions in a professional, efficient, and positive manner.
• Performs other duties and assignments as necessary.

Benefits

• Medical (including prescription)
• Supplemental insurance
• Dental
• Vision
• Life and AD&D insurance
• Short- and long-term disability
• Flexible spending accounts
• Retirement plans
• Tuition assistance
• Voluntary benefits (group rates on insurance and discounts)
• Tuition discounts at Thomas Jefferson University after one year of full time service or two years of part time service.

What This Job Offers

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