Clinical Documentation Improvement Specialist

Role and Responsibilities:

Primary responsibility is to facilitate improvement in the overall quality, completeness, and accuracy of clinical documentation.  Through concurrent interaction with physicians, nurses, case managers, coders and other health care team members, the Clinical Documentation Integrity Specialist (CDIS), will strive to ensure comprehensive medical record documentation that reflects the clinical treatment, decisions, and diagnosis for all Medicare inpatients.  Serving as a resource to all members of the health care team on documentation guidelines, this position will provide guidance and support, as well as assisting with education and training related to improving clinical documentation.  This position will actively participate in educating appropriate hospital and medical staff about ICD-10.   Additionally, the CDIS will:

• Abstract clinical data from the medical record to accurately code and sequence diagnoses and procedures ensuring accuracy of medical record documentation to support maximum reimbursement


• Concurrently abstract information from the medical record in accordance to the conventions and rules associated with the International Coding Classification of Diseases and Operations


• Abstract information from the medical record in accordance with abstracting guidelines as defined by Meditech, the medical center, HCFA, state and federal databases.


• Other duties as assigned by the Director

ESSENTIAL DUTIES AND RESPONSIBILITIES

• Conducts daily reviews of inpatient medical records either in the nursing unit and/or on the computer to identify missing, vague, and/or incomplete diagnoses and procedures


• Conducts timely follow-up reviews of clinical documentation to ensure that issues discussed and queries left in the medical record have been answered by the provider


• Utilizes coding and clinical expertise to identify opportunities and ensure the accuracy and completeness of clinical documentation for measuring and reporting physician and hospital outcomes


• Queries physicians on specificity of procedures performed and diagnosis based on accepted coding guidelines, clinical expertise and LifePoint Hospitals policy


• Tracks and trends specific opportunities for improvement through the query process utilizing approved metrics reporting


• Conducts educational sessions with physicians and other health care team members on documentation requirements


• Conducts CDI on-boarding education of all new admitting physicians as part of the hospitals orientation program


• Reviews clinical issues and identified query response concerns with physician advisors


• Participates in data collection to document findings and outcomes to drive quality improvement and improved clinical documentation


• Stays current with requirements of CMS Inpatient Prospective Payment Systems (IPPS), AHA Coding Clinic and Official Guidelines for Coding and Reporting related to ICD-10


• Participates in department and facility Quality and Performance initiatives


• Works closely with nursing, case management, quality, risk management, and medical staff credentialing to provide data related to key clinical indicators and operational metrics


• Works in conjunction with the Director of Quality, Medical Staff Credentialing and medical staff leadership to assure effective monitoring and successful completion of identified plans for improvement


• Prepares and presents educational programs to all internal constituents related to clinical documentation issues and coordinates same with clinical staff, physicians, compliance and coding staff


• Makes regular reports of progress toward goals associated with clinical documentation improvement opportunities and operational improvement plans


• Establishes cooperative working relationship with diverse groups and individuals, medical staff and other health care disciplines and interact with all levels of employees


• Develops and maintains a professional working relationship with medical staff, clinical staff, medical records and business office staff


• Maintains a knowledge base of the characteristics of disease, illness, disabling conditions that directly impact the patient’s state of physical or mental health


• Collaborates, coordinates and consults with members of the healthcare team to facilitate appropriate documentation in the medical record for concurrent chart abstraction and coding


• Understands the legal and ethical issues pertaining to confidentially as well as liability issues for coding activities


• Attends meetings as required and participates on committees and teams as directed

SKILLS REQUIRED

Customer Relations Skills:

Interacts in a positive way with: Co-workers, Supervisors, and Hospital Staff.  Interacts in a positive and courteous manner with: Physicians, Patients, Families and Guests.  Provides assistance and guidance as necessary.  Communicates related information when appropriate and/or refers to source of needed information.  Uses the appropriate forms to document customer service issues.

Communication Skills:

Communicates in a positive, courteous and helpful way.  Follows the appropriate lines of communication in bringing problems or concerns to: Department Head and/or Administration. Communicates and listens in an effective manner.

Professionalism:

Attends annual mandatory in-services.  Complies with Medical Center policies, and departmental procedures, objectives and improvement activities.  Must guard against the unauthorized release of confidential information and must realize that any breach of confidentiality will result in the immediate dismissal.  Follows established hospital and/or departmental procedures for dress, personal hygiene, and ID badges, recognizing that proper appearance assists in maintaining a professional image and authority.  Acknowledges project requests and follows through in an acceptable time frame.

EDUCATION AND EXPERIENCE

• Education and Training: Licensed Registered Nurse, RHIA, RHIT, CCS, Paramedic, LPN or combination thereof preferred.  Prior experience in case management, utilization review, clinical documentation improvement, and/or coding accuracy preferred.


• Experience: Minimum of 4 years’ experience in an acute adult in-patient clinical role for RNs, Paramedics and LPNs with demonstrated critical thinking skills or a minimum of two years’ experience with inpatient coding for coders, process improvement in an acute care facility preferred or equivalent experience.  Certified Clinical Documentation Improvement Specialist (CCDS) or Certified Documentation Improvement CDI Practitioner preferred. Bachelor’s degree in nursing may be substituted for two years of the required work experience. Knowledge of concurrent coding and documentation improvement, preferred.    Experience in development of reference based continuing educational programs using Adult Learning Principles.  Must be self-motivated and have the ability to work within the established policies, procedures and practices prescribed by the facility, corporation and the immediate supervisor.


• Affiliations: TBD.

PHYSICAL ABILITIES & WORK ENVIRONMENT

The physical demands described below are representative of those that must be met by an employee to successfully perform essential functions of the job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential duties and functions of the position. The list below of minimum essential functions is illustrative of the minimums only and is not a comprehensive listing of all functions and tasks performed.

• Ability to lift and move boxes up to 40 pounds.


• Ability to sit at a computer for prolonged periods of time.


• Ability to work in a typical office environment.


• Ability to tolerate stress.


• Ability to conduct tasks and successfully perform under critical deadlines.


• Ability of seeing and having depth perception is required


• Manual dexterity to operate office equipment and examine documents, records and files.


• Works in the following settings: patient care areas, office, and/or classroom environment.


• Sits, walks, and stands intermittently throughout workday.


• 90% of job requires computer data entry and use of software programs.


• Must be able to work independently and as a team member.