RN Clinical Documentation Improvement Specialist

Hunt Regional Healthcare • Greenville, TX

45d • Onsite

About The Position

The Clinical Documentation Improvement (CDI) specialist is responsible for facilitating the improvement in the overall quality and completeness of provider-based clinical documentation in the medical record. This onsite position will be responsible for assisting treating providers to ensure that documentation in the medical record accurately reflects the severity of illness of the patient as well as the level of services rendered. The CDI Specialist assesses clinical documentation through extensive review of the medical record, interaction with physicians, nursing staff, other patient care givers, and Health Information Management (HIM) coding staff to ensure that appropriate reimbursement is received for the level of services rendered to patients, and the clinical information utilized in profiling and reporting outcomes is complete and accurate.

Requirements

• Associates degree
• Three (3) years or more experience in medical record data abstraction related to coding, quality monitoring, or clinical documentation improvement.
• RN license
• Excellent communication, interpersonal, collaboration and customer relations skills.
• Ability to analyze data for patterns and trends.
• Strong critical thinking skills and ability to integrate knowledge.
• Prioritization and organizational skills.
• Working knowledge of Medicare reimbursement system, coding structures, medical necessity criteria preferred, but not required

Nice To Haves

• CDIP, CCDS, RHIT or RHIA credentials

Responsibilities

• Performs initial medical record review, within 24-48 hours of admission, using documentation improvement guidelines to evaluate overall quality and completeness of clinical documentation.
• Per review policies and procedures, conducts at least 2-3 follow-up reviews of clinical documentation prior to discharge to review any subsequent findings that have not been documented by the treating provider.
• Assigns a working DRG using official coding rules and guidelines to determine severity of illness, risk of mortality, risk adjustment, HCCs, and length of stay. Be familiar with MS-DRG/APR-DRGs and Inpatient Prospective Payment system (IPPS).
• Generate Recent Suggested Working DRG Report in Dolbey Fusion and forward to case managers daily.
• Queries providers on a concurrent basis as needed to clarify documentation in the medical records using ACDIS and AHIMA compliant query practices.
• Conducts post discharge reviews with HIM Coding staff when the working and final DRG do not match.
• Collaborates with the HIM Coding staff and/or CDI 2nd Level Review Auditor to review accounts with PPCs, PSIs, mortality reviews, and coding denials to determine any post discharge queries needed to clarify the conditions documented in the medical records for quality outcomes.
• Develops and conducts ongoing education for providers as well as new staff such as new CDI Specialists.
• Participates on internal committees as requested by the HIM Department Director.
• Maintains positive open communication with providers, case managers, coders, and other members of the care team as it relates to clinical documentation.
• Assists with special projects as needed and performs related duties as assigned by the HIM Manager and Director.

What This Job Offers

• Job Type: Full-time
• Education Level: Associate degree
• Number of Employees: 501-1,000 employees