Clinical Documentation Improvement Specialist

Nuvance Health • Poughkeepsie, NY

392d • $84,094 - $156,208

About The Position

The Clinical Documentation Improvement Specialist plays a crucial role in enhancing the quality, completeness, and accuracy of medical record documentation. This position involves extensive collaboration with healthcare professionals to ensure that clinical documentation accurately reflects the severity of illness and resource utilization. The specialist is responsible for educating the patient care team on documentation guidelines and ensuring compliance with established standards.

Requirements

• Registered Nurse (RN) with 5 years recent experience in medical/surgical, critical care, intensive care, or emergency room care preferred.
• BS or above preferred.
• Current NY/CT RN Licensure required.

Nice To Haves

• Strong interpersonal and communication skills.
• Ability to form positive, collaborative relationships with physicians and hospital staff.
• Analytical abilities to assist in obtaining solutions to problems.
• Ability to work independently and prioritize work.
• Ability to manage multiple priorities.
• Computer literate and willing to learn how to use computer applications relative to the job.
• Ability to problem solve in a proactive, creative manner using sound judgment based on factual information and clinical knowledge.

Responsibilities

• Facilitates appropriate clinical documentation to ensure the level of services and acuity of care are accurately reflected in the medical record.
• Accurately performs admission reviews for specific patient populations using clinical documentation guidelines.
• Communicates with ancillary personnel to clarify potential documentation opportunities.
• Extensively reviews all physician and clinical documentation, lab results, diagnostic information, treatment plans, and captures appropriate information in 3M.
• Utilizes clinical skills to identify documentation opportunities that reflect severity of illness, acuity, and resource consumption.
• Effectively communicates with appropriate physician(s) to ensure documentation opportunities are clarified.
• Utilizes AHIMA approved format to post physician queries 100% of the time.
• Updates 3M to reflect any changes in patient status, procedures/treatments.
• Accurately updates 3M to reflect additional physician documentation, lab findings, diagnostic test results, and treatment as appropriate.
• Effectively confers with physician to establish appropriate severity of illness and ensure documentation of principal diagnosis, comorbid conditions, complications, and procedures.
• Collaborates with coding staff as needed to determine appropriate DRG and required documentation.
• Provides clinical expertise and references to the coding staff as needed.
• Follows established guidelines for reconciling final coded DRG with the CDI DRG assigned at the time of discharge.
• Remains current with and conducts on-going education regarding the clinical documentation integrity program.
• Assists with the education of new staff, including new clinical documentation specialists, physicians, nursing, and allied health professionals.
• Tracks and trends personal performance using 3M data.
• Attends and participates in educational conferences.
• Participates in concurrent performance improvement activities and on-going MR review activities.
• Maintains positive and open communications with physicians, interdisciplinary care team members, Department Head, Lead Clinical Documentation Specialist, coding management, and coding staff.
• Demonstrates regular, reliable, and predictable attendance.

Benefits

• Competitive hourly wage ranging from $40.43 to $75.10.
• Part-time work schedule.
• Opportunities for ongoing education and professional development.

What This Job Offers

• Job Type: Part-time
• Career Level: Mid Level
• Industry: Nursing and Residential Care Facilities
• Education Level: Bachelor's degree