Clinical Documentation Specialist II Full Time Days
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About The Position
DMC Harper University Hospital has distinguished itself in surgery and medicine and is known for its clinical expertise and innovative research. A specialty referral hospital, Harper has established Centers of Excellence in neurosciences, bariatric surgery, vascular services, multidisciplinary cardiovascular services, hypertension, stroke prevention and heart failure. The Clinical Documentation Specialist (CDI) level II 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 with clinical documentation guidelines and established policies/procedures. The CDI II 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, nurses, 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. CDI level II is an intermediate level position for experienced CDI and must demonstrates all skills of CDS I & II with < 5% error rate.
