Clinical Documentation Improvement Specialist - Clinical Doc Integrity - FT Days

Sky Lakes Medical Center•Klamath Falls, OR

38d•$79,747 - $126,048•Onsite

About The Position

The Clinical Documentation Improvement Specialist will focus on clinical documentation integrity. This role requires a strong clinical background and the ability to analyze patient records to identify opportunities for improvement in physician documentation. The specialist will work to ensure accurate assignment of MS-DRG, capture of co-morbidities/complications, and increase the specificity and accuracy of documentation. Effective communication with physicians and collaboration with other departments are key aspects of this role.

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 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.