Documentation Specialist Jobs

About The Position

Requirements

• A Baccalaureate degree or master’s degree in nursing.
• License to practice nursing in Iowa.
• A minimum of two (2) years of recent work experience as a Clinical Documentation Improvement Specialist with at least three (3) years of clinical experience at an academic medical center.
• At least one (1) year of managerial or supervisory experience, ELA acceptable
• Advanced clinical expertise and extensive knowledge of complex disease processes with a broad clinical experience in an inpatient setting required.
• A broad knowledge of the disease process, normal/abnormal findings, and reasonable course of treatment, quality measures, and risk management issues is essential.
• Demonstrated competency in teaching/learning process, organizational skills and computer literacy required, including proficiency with computer software applications utilized within the CDI programs (i.e. Excel, Word, PowerPoint, 3M 360)
• Excellent professional demeanor and communication skills
• Excellent people skills with physicians, nursing staff, and interdisciplinary team members as demonstrated through written and verbal communication, including presentation and training skills.
• Excellent organizational, time management and critical thinking skills
• Currently holds Clinical Documentation certification OR obtains certification within one (1) year, i.e.: Certified Clinical Documentation Specialist (CCDS), or Certified Documentation Improvement Practitioner (CDIP)
• Electronic Medical Records experience (EPIC preferred).
• Experience with performance improvement methodologies
• Experience with data mining and/or data analytics

Nice To Haves

• Healthcare education experience with a strong understanding of the requirements for clinical coding and billing according to the rules of Medicare, Medicaid, and commercial payers preferred.
• Extensive knowledge of CDI related quality measures, including AHRQ measures and AHIMA query practice guidelines, knowledge of coding structures/national coding guidelines and related appropriate chart documentation.
• Demonstrated knowledge of healthcare outcomes and performance improvement initiatives/techniques.
• Current coding certification (CPC, CCS, RHIA/RHIT) or additional outpatient CDI certification (CCDS-O)
• Experience with hospital quality/safety metrics.
• Experience working at large academic medical centers.
• Holds a quality related certification.

Responsibilities

• Coordinates documentation improvement & coding audits, providing physician documentation improvement education at the department level.
• Makes decisions regarding documentation for accurate ICD-10-CM/ICD-10-CM-PCS code assignment and quality related challenges.
• Accountable for CDI nursing and department level successes as demonstrated through various indices which include but not limited to accurate Severity of Illness (SOI) / Risk of Mortality (ROM) capture rates, Complicating or Comorbid Condition (CC) / Major Complicating or Comorbid Condition (MCC) capture rates, Case Mix Index (CMI) analysis, physician query- response rates, and tracking financial variances, while providing guidance, coaching, and counseling to staff to assure outcomes and goals are achieved.
• Works with program leadership to plan, develop, and implement clinical documentation education programs for clinical care providers, staff, the CDI Specialist team, including resident and new provider orientation, and onboarding for CDI Specialists and patient care teams.
• Institutes strategies that facilitate effective collaboration between the Director, Clinical Documentation Improvement, Director/Manager of Health Information Management, Administration, and other applicable departments as it relates to clinical documentation improvement.
• Maintains and shares expertise with MS-DRG/APR-DRG’s and Inpatient Prospective Payment System (IPPS), CMS guidelines and Official Coding Guidelines.
• Works closely with Health Information Management, Clinical Documentation Specialists and the Quality Improvement Program to successfully identify, review and develop education on patient safety indicators, hospital acquired conditions and other quality driven measures.
• Assist to maintain positive relationships with other departments and University colleges to facilitate collaboration and achievement of department, hospital, and UI Health Care goals.
• Represents the CDI Director on hospital and UI Health Care subcommittees; chairs committees as requested.
• Represents the UI Health Care on various internal and external committees and associations as requested by leadership.
• Works with CDI physician advisors to ensure clear understanding of their role and improve ongoing quality improvement for CDI.
• Reviews inpatient medical records prospectively to ensure that the care of the patient is recorded in language the payers can interpret, and which accurately depicts the acuity of the patient and resources expended.
• Reviews surgical procedures to ensure documentation is accurate for ICD-10/PCS code assignments.
• Works with the analytics team, leadership, and the coding department to assess documentation gaps and formulate appropriate CDI educational tools.
• Tracks, trends, and Reviews data/metrics with team members and service line providers at meetings, as well as on an individual basis with a focus on strategies and education that facilitate documentation improvement and denials management.
• Super-user level responsibility for vendor and software applications utilized by Clinical Documentation Improvement, the Quality Improvement Program, and HIM.
• Manages projects that provide support across the spectrum of documentation improvement from identifying and educating interdisciplinary champions to identifying and implementing process improvement/efficiencies and tracking/auditing of metrics to indicate successes or improvement areas.
• Works with leadership on projects to provide onsite support and education to CDI nursing staff, coders, physicians, case managers, and administration to ensure improved documentation reflecting the quality of care provided across all departments and interdisciplinary care teams.
• Manages multiple projects necessary to promote accurate concurrent documentation from all disciplines (physicians, case managers, nurses, dietitians, wound care specialists etc.) to capture best practice documentation for specific diagnoses.
• Ensures successful completion of projects to provide overall improvement of quality and completeness of clinical documentation and directly manages activities related to improving clinical documentation that is consistent with the mission of the organization and the values critical to the future of the organization.
• Develops supporting documents to present to CDI Director and other stakeholders to solidify scope, propose additional resources, and update on project schedule/results.
• Assists CDI Director with the preparation of data and reports to evaluate the effectiveness and overall impact of the clinical documentation improvement program for presentation to the Clinical Documentation & Coding oversight committees.
• Leads CDI committees; meeting regularly to review process for quarterly updates to the program that ensures continued high-quality engaged onboarding of new CDI nurses, and development of staff within departmental and intradepartmental committees
• Leads CDI Clinical Documentation Guidelines Committee, CDI Query Template Committee, CDI Newsletter Committee
• Performs routine audits of documentation queries to identify knowledge gaps and improve the accuracy of quality related documentation, capture, and query processes.
• Evaluates regulatory changes related to quality measures and educates staff appropriately.
• Knowledgeable of legal issues involved in patient care information and exercises considerable judgment relative to HIPAA issues and compliance, including AHIMA query practices.
• Collaborates with the inpatient coding team and their leadership to ensure adherence to established processes, providing second level quality reviews when necessary.
• Works closely with Physician Advisor(s)/Quality Leadership/CDI Director on escalated cases to ensure that the appropriate documentation is added to the medical record, collaborating with the inpatient Coding team and Clinical Informatics team and their leadership to ensure adherence to established processes, and providing second level reviews when necessary.
• Evaluates regulatory changes and educates staff appropriately.
• Creates and implements consistent training and development for nursing staff, physicians and mid-level practitioners that address documentation issues and variances related to quality metrics and measures.
• Teaches and mentors other Clinical Department Specialists on clinical documentation improvement principles and concepts, serving as a resource person to key stakeholders across the organization.
• Leads CDI onboarding program to ensure efficient and complete education and development of clinical documentation specialists.
• Maintains a climate of learning that promotes educational experiences for all levels of staff.
• Assists with implementation of system and process changes, including ongoing Clinical Documentation Improvement staff training.
• Provides daily oversight and supervision of CDI Specialists/RNs.
• Promotes department and organizational policy compliance and development with CDI Director.
• Leads quarterly review meetings with individual CDI nurses and CDI Director.
• Has regular, reliable, predictable attendance in the performance of essential functions while meeting or exceeding expected timelines on performance level as it relates to personnel, and reporting responsibilities.
• Acts as delegate for Director when necessary
• Hires, develops, and manages the performance of staff; assures staff are compliant with UI policies and procedures.
• Develops and implements policies and practices of a culture that supports staff engagement.
• Holds employees accountable for high performance and high engagement culture by sharing data, articulating expectations, monitoring performance, and providing feedback consistency across areas of responsibility.
• Identifies and provides opportunities for the staff to develop knowledge, skills, and abilities needed to contribute to the success of the department.
• Provides actionable quality-driven feedback for leadership and CDI specialist that allows consistent accountability supporting high performance and a high engagement culture, by articulating expectations, monitoring performance, and providing feedback consistency across areas of responsibility.
• Assists with compliant record keeping and tracking relative to staff education.
• Provides back up as a mentor/resource to the CDI nursing team, as needed.

Benefits

• paid vacation
• sick leave
• health, dental, life and disability insurance options
• generous employer contributions into retirement plans