RN - Clinical Documentation Specialist II -HIM CDI

University of Mississippi Medical Center • Jackson, MS

38d

About The Position

To support and review the inpatient medical record in order to facilitate improvement in overall quality, completeness, clinical severity, and accuracy of inpatient clinical documentation for DRG based or APR based payor population for specific departments or areas. To obtain and promote appropriate clinical documentation through extensive interaction with physicians and other members of the healthcare team.

Requirements

• Five (5) years of clinical nursing in Acute Care, Utilization Review, Case Management, Quality Management and/or Hospital-based Clinical Documentation experience.
• Valid RN license.
• Knowledge of evidence-based clinical guidelines across a wide variety of conditions and age groups.
• Knowledge of resource/utilization management.
• Skill in the use of personal computers and related software applications.
• Ability to manage multiple priorities under time constraints; ability to analyze and solve problems.
• Understanding of cost and quality issues.
• Excellent verbal and written communication skills.
• Interpersonal skills to interact with a wide range of constituencies.
• Decision-making skills.
• Demonstrated ability to perform and maintain working relationships within the department and across all business units to foster a team environment.
• Effective written and verbal communication skills required.
• Proficient knowledge and experience in Microsoft office Suite (Excel, PowerPoint, Word & Outlook).

Nice To Haves

• Hospital based Clinical Documentation experience preferred.
• CCDS (Certified Clinical Documentation Specialist) preferred upon hire, but is required within three years of hire.
• Healthcare revenue cycle experience preferred.

Responsibilities

• Reviews inpatient medical record within 24-48 hours of admission to ensure accuracy and completeness and identifies documentation opportunities that reflect severity of illness, acuity, and resource consumption. Assigns a working DRG based on principal diagnosis and procedure. Identifies comorbidities and complications. Identifies Present on admission diagnoses. Identifies quality issues and reports to the responsible party. Is proficient in more complex decision-making with high degree of accuracy.
• Reviews and enters information in both epic and 3m 360 as required. Proficient in using these software systems.
• Ensures accuracy by reviewing inpatient charts every 24-48 hours as a follow-up. Identifies documentation that reflects the severity, acuity, quality issues and resource consumption and updates his/her findings in 3m 360 software. Proficient in quality and production.
• Communicates with physicians and other patient care providers, both verbally and written in a clear and concise way, regarding documentation opportunities for improvement. Assists in development and presentation of educational materials regarding documentation to both cdi staff and/or providers and other members of the healthcare team.
• Proficient effective assessment skills to identify clinical indicators for diagnoses. Integrates new or current techniques (of procedures or surgery, cdi issues, opportunities for documentation improvement) to obtain information as it relates to the planning, implementing, and evaluating of patient care documentation.
• Provides timely internal/external customer service in a cooperative, professional, and respectful manner.
• Ability to formulate a more complex query in order to obtain clarifications of conflicting, ambiguous, or non-specific documentation, by verbal or written compliant queries. Ability to determine when it is appropriate to escalate an issue to senior team member, provider, or administrator.
• Collaborates with CDI Specialist III to review individual problematic cases and/or educational needs.
• Has a highly developed understanding of what constitutes a risk management and/or quality program (PSI/HAC) case, and discusses with senior team member, as appropriate.
• Must maintain a current ACDIS Certification status. Participates in CDI-related education activities to maintain certifications and licensures.
• Conducts independent research to promote knowledge of clinical topics, coding guidelines, regulatory policies and trends, and healthcare economics.
• Contributes to a positive work environment and performs other duties as assigned or directed to enhance the overall efforts of the organization.
• Maintains UMMC network security of personal health information of the medical record. Employee must set aside a dedicated workspace at home. Employee must ensure that confidential material cannot be accessed or viewed by unauthorized person during their working hours. All information containing any phi (personal health information) must be shredded.
• Performs any other assigned duties since the duties listed are general in nature and are examples of the duties and responsibilities performed and are not meant to be construed as exclusive or all-inclusive. Management retains the right to add or change duties at any time.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Industry: Ambulatory Health Care Services
• Education Level: No Education Listed
• Number of Employees: 5,001-10,000 employees