Clinical Documentation Specialist 1

University of Miami • Hialeah, FL

10d • Onsite

About The Position

The Clinical Documentation Specialist I (CDI) provide clinically based concurrent and retrospective review of inpatient medical records to evaluate the documentation and utilization of acute care services. The CDI I facilitate accurate documentation for severity of illness and quality in the medical record. This involves extensive record review, interaction with physicians, health information management professionals, and nursing staff. Active participation in team meetings and education of staff in the Compliant Documentation Management Program (CDMP) process is a key role. Facilitates appropriate physician documentation of care to accurately reflect patient severity of illness and risk mortality. Obtains accurate and compliant reimbursement for acute care services and reports quality of care outcomes. Collects data regarding timeliness of report completion to assist physicians in meeting applicable rules and regulations. Verifies the documentation of the correct admission type and follows up on incorrect assignments immediately. Directs clinical documentation improvement and data abstraction. Ensures accurate and timely reviews of inpatient records. Adheres to University and unit-level policies and procedures and safeguards University assets.

Requirements

• Bachelor’s degree in Nursing, Health Information Management, or related medical field required.
• Graduate Foreign Medical degree will be considered.
• Current RN, MD or RHIA required
• At least two (2) years direct patient care in acute care setting or (3) years inpatient coding experience required.
• Demonstrated extensive clinical knowledge, critical-thinking skills, and understanding of disease processes, anatomy, pathophysiology, and disease management/treatment required.
• Proficiency with Microsoft Office (Excel, PowerPoint, Word, Outlook) required.
• Proficiency with technology/software required.
• Excellent written and verbal communication skills; ability to write concisely and effectively when communicating with providers.

Nice To Haves

• CCDS or CDIP certification preferred; shall obtain CCDS or CDIP within 3 years from date of hire
• Coding certification (CCS, CIC, or CPC) preferred
• Prior clinical documentation improvement (CDI) experience preferred.
• Experience with 3M 360 Encompass preferred.

Responsibilities

• Facilitates appropriate physician documentation of care to accurately reflect patient severity of illness and risk of mortality.
• Reviews medical records and identifies potential gaps in clinical documentation for all assigned patient types and payer populations as directed on admission and throughout the hospitalization.
• Performs initial, concurrent review and follow up on assigned population consistent with department volume and frequency requirements.
• Assigns working DRG based upon identification and selection of principal diagnosis, complications, or co-morbid conditions and/or valid OR procedures, including capture of POA indicators.
• Ensures documented conditions, clarifications, and coded diagnoses are clinically supported.
• Documents reviews and other pertinent information in designated systems by established deadlines.
• Uses clinical judgement to determine when and/or if a query is necessary.
• Queries physicians within established timelines via approved query forms for conflicting, imprecise, incomplete, illegible, or inconsistent documentation by requesting and obtaining additional documentation within the health record when appropriate.
• Uses clinical judgement to determine appropriate and relevant clinical indicators and to discern appropriate reasonable diagnostic options when formulating non-standard queries.
• Interacts with Physicians to complete/resolve queries prior to patient discharge.
• Performs timely reconciliation of CDI-assigned DRG against final coded DRG.
• Escalates DRG mismatches as appropriate per established departmental protocols.
• Develops collaborative relationships to facilitate accomplishment of work goals.
• Possesses excellent interpersonal skills in building, negotiating, and maintaining crucial relationships.
• Demonstrates a willingness and ability to assist others.
• Understands and supports documentation strategies (upon completion of training) and continues to educate self and team members using educational tools, videos and provided WebEx’s.
• Recognizes opportunities for documentation improvement using strong clinical skills/knowledge.
• Uses critical thinking and sound judgment in decision making for reimbursement considerations in balance with regulatory compliance.
• Strategically educates members of the patient-care team regarding documentation regulations and guidelines, including house staff, attending physicians, allied health practitioners, nursing, and care management.
• Effectively and appropriately communicates with physicians and other healthcare providers as necessary to ensure appropriate, accurate and complete clinical documentation.
• Communicates with HIM staff and collaborates with them to resolve discrepancies with DRG assignments and other coding issues.
• Complete well-timed follow-up case reviews (and secondary reviews as needed) on all concurrent cases with priority given for resolution of those with clinical documentation clarifications.
• Participate in meetings, including feedback on outstanding issues, presentations for educational opportunities and any other needs identified.
• Other duties may be assigned.
• Collects data regarding timeliness of report completion to assist physicians in meeting applicable rules and regulations.
• Verifies the documentation of the correct admission type and follows up on incorrect assignments immediately.
• Adheres to University and unit-level policies and procedures and safeguards University assets.

Benefits

• medical
• dental
• tuition remission

What This Job Offers

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