Clinical Documentation Improvement Specialist

Sharp HealthCare • San Diego, CA

1d • Onsite

About The Position

The Clinical Documentation Improvement Specialist (CDIS) reviews inpatient medical records while patients are still in-house (concurrent review) for proper documentation resulting in appropriate reimbursement, severity of illness, risk of mortality, quality measures and risk adjustment. This review includes new admissions to the facility, as well as re-reviews every two to three days until the patients are discharged. The CDIS communicates with clinicians and physicians to ensure timely and accurate documentation for all designated payer(s) and provides training and education as needed. The role collaborates with many departments such as HIM, Quality, and Service lines to improve documentation, reimbursement and Quality measures internally for Sharp Healthcare as well as publicly reported measures.

Requirements

• 5 Years Experience in nursing or other clinical area of an acute care facility
• California Registered Nurse (RN) - CA Board of Registered Nursing -REQUIRED

Nice To Haves

• Bachelor's Degree in Nursing
• Emergency or critical care nursing background
• Experience working with an EHR, preferably Cerner Millennium
• CDIS certification preferred
• Working knowledge of regulatory coding guidelines preferred

Responsibilities

• Reviews inpatient medical records while patients are still in-house (concurrent review) for proper documentation resulting in appropriate reimbursement, severity of illness, risk of mortality, quality measures and risk adjustment.
• Conducts reviews of new admissions to the facility, as well as re-reviews every two to three days until the patients are discharged.
• Communicates with clinicians and physicians to ensure timely and accurate documentation for all designated payer(s).
• Provides training and education as needed.
• Collaborates with HIM, Quality, and Service lines to improve documentation, reimbursement and Quality measures internally for Sharp Healthcare as well as publicly reported measures.
• Assures any clarification is documented appropriately in the patient's record according to policy.
• Follows-up with physician, if appropriate.
• Improves accuracy, documentation specificity and completeness with real-time interactive communication and education of physicians, clinicians, and other involved parties regarding the necessity of providing complete and clear documentation of the care provided throughout a patient's stay.
• Works daily with physicians to improve documentation capture of diagnosis specificity, all secondary diagnoses, and procedures during the patient stay.
• Achieves documentation improvement goals using clinical knowledge to deploy queries, face-to-face communications, and/or other educational programs and tools.
• Collaborates with Clinical Informaticists, Physician Informaticists, and Specialists regarding EMR documentation, education and system improvements.
• Demonstrates content expertise regarding applications and business operations by supporting clients and receiving customer feedback.
• Manages client expectations, priorities, and attainment of project goals through effective communication.
• Recommends workflow and technical improvements to various electronic documentation tools.
• Abides by all documentation and coding conventions, ethical and professional standards and rules established by the Center for Medicare and Medicaid (CMS), and the American Health Information Management Association (AHIMA) for assignment of diagnostic and procedure codes and ultimately a working DRG.
• Adheres to AHIMA query guidelines.
• Remains current with coding and documentation improvement techniques to support accuracy of codes and the resulting working DRG assigned.
• Participates in educational programs and in-services in order to maintain and exceed excellence in documentation and coding skills.
• Participates in the peer review process as both a reviewer and reviewee as a means of education and feedback to peers and self.
• Collaborates with the Quality Team to determine if documentation supports or negates an AHRQ patient Safety indicator and or Hospital Acquired Condition.
• Reviews record to identify appropriate risk adjustment diagnoses which are relevant and may impact the scoring or quality of the documentation.

Benefits

• Sharp HealthCare is an equal opportunity/affirmative action employer. All qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, gender, gender identity, sexual orientation, age, status as a protected veteran, among other things, or status as a qualified individual with disability or any other protected class

What This Job Offers

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