Clinical Documentation Improvement (CDI) Specialist - Health Information Management (HIM), FT (EXEMPT)

Career Department

Health Information Management

Status

Full Time

Shift

8:00am-4:30pm

Average Weekly Hours

40

JOB SUMMARY

The CDI Specialist is responsible for facilitating the improvement in the overall quality and completeness of the medical record.  This position collaborates extensively with physicians, nursing staff, other patient caregivers, and HIM coding staff to ensure that the level of services and acuity are accurately reflected in the medical records.  The CDI Specialist promotes modification to medical record documentation by facilitating concurrent modifications through query documentation to insure appropriate and equitable reimbursement for services rendered to patients with a DRG based payer (Medicare, Medicaid), Hierarchical Condition Categories and Risk Adjustment.  This position plays a key role in reporting quality of care outcomes, specifically addressing data trends, timeliness, provider compliance, and financial opportunities, in measurable values.   The CDI specialist is an excellent communicator between healthcare providers, case management, coding specialist and other nursing staff.  The role as educator is required; the position serves as a subject matter expert for clinical documentation improvement engagements and other clinical focused revenue cycle engagements.

PRIMARY JOB RESPONSIBILITIES

The Clinical Documentation Specialist will be responsible for facilitating concurrent documentation of the medical record to achieve accurate inpatient and outpatient coding and legitimate DRG and HCC assignment.  The duties and responsibilities will include the following:

• Initiate and perform concurrent documentation review of selected inpatient and outpatient clinic records to clarify conditions/diagnoses and procedures where inadequate or conflicting documentation exists.
• Ensure the accuracy and completeness of clinical information used for measuring and reporting physician and hospital outcomes.
• Communicate with the individual physician or medical staff departments to facilitate complete and accurate documentation of the inpatient and outpatient clinical record.
• Serve as a resource for physicians to help link ICD-10-CM coding guidelines and medical terminology to improve accuracy of final code assignment.
• Conducts follow-up reviews of clinical documentation to ensure points of clarification have been recorded in the patient’s chart.
• Works in a collaborative fashion with the providers and coding specialists in concurrent reviews of clinical records to identify active and hierarchical conditions.
• Work in a collaborative fashion with the health information management department in concurrently reviewing the inpatient medical record to assure correct provisional and final DRG assignment.
• Assist the HIM department in facilitation of the physician query process.
• Identify opportunities for intradepartmental and interdepartmental operational improvements.
• Monitor and evaluate effectiveness of concurrent coding outcomes at designated intervals for severity of illness, morbid and co-morbid conditions.
• Report physician profiling/score cards/core measure trends to hospital departments and committees at designated intervals.
• Develop and implement CDI strategies by capitalizing on facility and industry best practices to achieve targeted outcomes.
• Maintain accurate records of review activities to comply with departmental and regulatory agency guidelines.

Acts as organizational consultant and provides education for members of the patient care team, including medical staff, on documentation guidelines on an on-going basis

Requirements Include

EDUCATION AND WORK EXPERIENCE

• Education: RN; BSN, Registered Health Information Management Administrator, Register Health Information Management Technician, Certified Coding Specialist or Certified Clinical Documentation Specialist preferred
• Experience: 5 years recent clinical experience in a hospital setting, or 4 years recent clinical experience. Utilization Review or coding experience preferred.
• Current Ohio nursing license and certifications.

KNOWLEDGE AND SKILLS

• Essential Technical/Motor Skills: Requires excellent observation skills, analytical thinking, problem solving, plus good verbal and written communication.
• Interpersonal Skills: Professional, team player, able to communication well with others. Strong interpersonal skills, pleasing personality, positive. Regular significant contacts with other personnel throughout and outside the facility.
• Essential Mental Abilities: Good critical thinking skills, able to assess, evaluate, and teach. Flexible with a working knowledge of all areas of adult medicine.