Clinical Documentation Specialist I
About The Position
The Clinical Documentation Specialist (CDI) I, reports to the Market Clinical Documentation Specialist Manager. Under limited direction works collaboratively with medical, nursing and ancillary staff, and case managers and coders to improve the overall accuracy, quality and completeness of clinical documentation in accordance to clinical documentation guidelines and established policies/procedures. The CDI will be responsible for performing initial and follow up reviews of selected patient accounts both while hospitalized or after discharge to identify appropriate documentation accuracy and identify gaps and opportunities to reflect the level of service rendered to all patients. Ensures the accuracy and completeness of clinical information used for measuring and reporting quality services and performance of specific quality outcomes. Oversees clinical documentation patterns and trends to identify areas of improvement in documentation and performance measures. Educates all members of the patient care team regarding clinical documentation needs, changes to clinical documentation guidelines, coding and reimbursement issues, and quality performance documentation requirements on an on-going basis. Develops and conducts on-going Performance Documentation education for new staff including case managers, coders, physicians, residents, nursing and allied health professionals. Compiles, analyzes, and evaluates quality and clinical data collected as part of an integrated system-wide program of clinical improvement and documentation requirements. Provide full CDI coverage to the designated facility as per the CDI Department guidelines and directions.
Requirements
- Reports to the Market Clinical Documentation Specialist Manager.
- Works collaboratively with medical, nursing and ancillary staff, and case managers and coders.
- Improves overall accuracy, quality and completeness of clinical documentation in accordance to clinical documentation guidelines and established policies/procedures.
Responsibilities
- Performing initial and follow up reviews of selected patient accounts both while hospitalized or after discharge to identify appropriate documentation accuracy and identify gaps and opportunities to reflect the level of service rendered to all patients.
- Ensuring the accuracy and completeness of clinical information used for measuring and reporting quality services and performance of specific quality outcomes.
- Overseeing clinical documentation patterns and trends to identify areas of improvement in documentation and performance measures.
- Educating all members of the patient care team regarding clinical documentation needs, changes to clinical documentation guidelines, coding and reimbursement issues, and quality performance documentation requirements on an on-going basis.
- Developing and conducting on-going Performance Documentation education for new staff including case managers, coders, physicians, residents, nursing and allied health professionals.
- Compiling, analyzing, and evaluating quality and clinical data collected as part of an integrated system-wide program of clinical improvement and documentation requirements.
- Providing full CDI coverage to the designated facility as per the CDI Department guidelines and directions.
Benefits
- Medical, dental, vision, and life insurance
- 401(k) retirement savings plan with employer match
- Generous paid time off
- Career development and continuing education opportunities
- Health savings accounts, healthcare & dependent flexible spending accounts
- Employee Assistance program, Employee discount program
- Voluntary benefits include pet insurance, legal insurance, accident and critical illness insurance, long term care, elder & childcare, auto & home insurance
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What This Job Offers
Job Type
Full-time
Career Level
Entry Level
Education Level
No Education Listed
