Clinical Documentation Specialist, III
The Clinical Documentation Integrity Specialist serves to provide a clinically based concurrent and retrospective review of all inpatient medical records to access and procure accurate and complete documentation of the diagnoses and procedures. The Clinical Documentation Integrity Specialist acts as a liaison between medical staff, nursing and coding to ensure the provider documentation reflects the most appropriate Severity of Illness (SOI), Risk of Mortality (ROM) and Intensity of Services (IOS) provided. Superior written and oral communication skills is essential. The Clinical Documentation Integrity Specialist possesses a high level of analytic critical thinking.
- Provides clinically based concurrent review of inpatient encounters to assess and procure accurate and complete documentation of all pertinent diagnoses and procedures.
- Ensures provider documentation accurately reflects quality of care, severity of illness and risk of morality to support correct coding, reimbursement and quality initiatives.
- Engages physicians or other departments regarding procedures/diagnoses to ensure proper documentation. This may include participation in educational sessions and active engagement with providers on the nursing units.
- Follows CDI program standards as outlined in The Clinical Documentation Inpatient Handbook.
- Consistently meets or exceeds all metrics for CDI performance. This includes productivity metrics, query and TRIC compliance, and < 5% missed query opportunities as evidenced through regularly scheduled CDI audits.
- Demonstrates a thorough working knowledge of the principal diagnosis, relevant secondary diagnoses, present on admission clarification, hierarchal condition categories, CC/MCC capture and relevant procedures with appropriate subsequent MS-DRG or APR-DRG assignment.
- Exhibits a command and understanding of The Official Guidelines for Coding and Reporting with updates published annually by The Centers for Medicare and Medicaid Services (CMS) and quarterly through Coding Clinic.
- Under the direction of the Clinical Documentation Integrity Manager: may perform formal education to providers, and ancillary department staff, may participate in intra-departmental meetings and initiatives and may serve as CDI liaison for facility/division initiatives.
- All tasks need to be performed following the Operating Principles of Steward Healthcare. Adheres to system and department compliance policies, and any and all applicable laws and regulations.
- Functions as subject matter expert to other CDI Specialists and assumes responsibility to mentor and develop other CDISs as assigned by CDI Manager or leadership.
- Demonstrates all skills of CDS II
- At the direction of CDI Manager and CDI leadership will perform other duties as assigned.
REQUIRED KNOWLEDGE & SKILLS:
- Must consistently demonstrate superior ethical performance as defined in the ACDIS Code of Ethics
- Must possess strong organization, communication and critical thinking skills
- Education: Bachelor’s degree in a clinical or coding study is preferred
- Experience (Type & Length): Minimum of 5 years acute Medical/Surgical clinical experience and 3 years of CDI experience required
- Certification/Licensure: RN with current licensure. CCDS or CDIP certification is required.
- Software/Hardware: Proficiency in EMR applications, CDI and coding software is mandatory with a working knowledge of basic Office software such as Microsoft Word, Excel, Outlook and PowerPoint.