RN - Clinical Documentation Integrity Specialist - 40hrs

Connecticut Children's Medical Center • Hartford, CT

2d

About The Position

Reporting to the Manager of CDI, this individual is responsible to identify physician documentation improvement opportunities, ensuring all relevant information is included and accurately reflects the patient’s condition and care. Works closely with physicians and other healthcare providers to clarify documentation and address any discrepancies and/or ambiguities. Participates in continuous close collaboration with the hospital Inpatient Coding team and other on related workflows. Remains current with the latest coding guidelines and documentation standards. Supports the overall success of the CDI program.

Requirements

• Education: Bachelors in Nursing (BSN).
• Experience: Minimum of 3 years of pediatric clinical experience required.
• At least one year of experience as a Clinical Documentation Integrity Specialist.
• License and/or Certification Required: Registered Nurse (RN).
• Holds a recognized credential from ACDIS (CCDS) or AHIMA (CDIP), AHIMA (CCS), or is willing to secure this credential within the first year of hire.
• Knowledge: Self-motivated, strong organizational skills, excellent speaking and presentation skills.
• Willingness to update technical expertise and to develop management/leadership skills through continuing education throughout tenure in position.
• Skills: Strong interpersonal and communication skills to manage competing priorities of the different stakeholders to ensure provision of high quality, high value and efficient care.
• Electronic medical record knowledge and use.
• Utilizes applicable electronic system(s) supporting job functions.
• Abilities: Learn/develop the skills necessary to perform Clinical Documentation review of medical records.
• Understand and communicate the impact of CC/MCC’s and other variables on the assignment of the various DRG methodologies.
• Handle multiple priorities and increasing responsibility.
• Collaborate with others to achieve a common goal through mutual cooperation.
• Influence others for positive and productive outcomes.
• Quickly process complex problems, identify key components, and develop plans for resolution.
• Able to understand and utilize necessary computer systems.

Nice To Haves

• Experience: Previous UR/CDI, case management or care coordination preferred.
• 5 years of nursing experience in either Med/Surg, Intensive Care, additional Pediatric and NICU experience preferred.
• 1 year of experience in Clinical Documentation Integrity
• License and/or Certification Preferred: CCDS and CCS or, CDIS and CCS, or CDIS, CCDS, CCS.

Responsibilities

• Provides review of medical records to facilitate appropriate physician documentation of clinical conditions and procedures. -20%
• Analyze medical records to support appropriate severity of illness, expected risk of mortality, complexity of care for the patient, Present on Admission indicator(s), quality measures (Hospital Acquired Conditions, Patient Safety Indicators, etc.), and other focus areas as needed and where applicable. -20%
• Maintains knowledge of ICD-10 diagnosis and PCS procedure coding, MS and APRDRG assignments, clinical conditions, and documentation practices. -5%
• Educates members of the patient care team regarding documentation guidelines, including physicians and extenders, and clinical service areas when appropriate. -10%
• Helps ensure timeliness of all written and verbal queries from providers to ensure proper documentation is obtained and placed in the medical record prior to the patient’s discharge, and post discharge if requested by the Inpatient Coding team. -20%
• Maintains communication with providers as necessary to help ensure timely, complete and accurate medical record documentation. -5%
• Communicates with coworkers in an open and respectful manner that promotes knowledge sharing and teamwork by way of electronic messaging, video and telephone conferencing and in person as needed. -5%
• Follows the United States Department of Health and Human Services (USDHHS) ICD-10-CM Official Guidelines for Coding and Reporting. -5%
• Follows standards of ethical coding and coding interpretive guidelines set forth by AHIMA, ACDIS and the AHA Coding Clinic and other regulatory references as applicable. -5%
• Performs other job-related duties as assigned.

What This Job Offers

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