Clinical Documentation Specialist-Full Time

Job Description:

Clinical Documentation Specialist-Full Time

The Clinical Documentation Integrity Specialist I (CDI) is responsible for utilizing independent clinical judgement in facilitating the integrity, overall quality, accuracy, and completeness of provider-based clinical documentation in the medical record. This position is responsible for collaborating with healthcare providers to ensure the documentation in the medical record accurately reflects the severity of illness and risk of mortality of the patient. The CDI Specialist assesses the clinical documentation through extensive reviews of the medical record, interaction with all members of the healthcare team and the Healthcare Information Management (HIM) Coding team to ensure appropriate coding and Diagnosis Related Group (DRG) assignment for the level of services rendered to the patient and to ensure that the clinical information utilized in profiling and reporting outcomes is complete and accurate.

Responsibilities

Essential Duties and Responsibilities:

• Ensures determination of working Diagnosis Related Group (DRG) assignment and applying clinical expertise to identify opportunities for improved or clarified documentation that accurately reflects the severity of illness (SOI) and risk of mortality (ROM) of the patient.
• Direct and timely follow-up with clinical providers to ensure requested clarification is provided.
• Learn clinical documentation integrity (CDI) skills (research, technology, treatment modalities, etc.)
• Utilize critical thinking/problem solving processes in chart review process to determine diagnoses and procedures
• Learn to utilize professional association resource materials and regulatory agencies guidelines to enhance own skill sets: Coding Clinics, American Health Information Management Association (AHIMA), Association of Clinical Documentation Integrity Specialists (ACDIS), Centers for Medicare and Medicaid Services (CMS) guidelines.
• Learn and gain knowledge of writing concurrent and retrospective queries for clarification of information in the medical record necessary to appropriately assign diagnoses and procedures
• Learn to establish and reconcile Diagnosis Related Group (DRG) processes compliant with departmental guidelines and Centers for Medicare and Medicaid Services (CMS) regulations.
• Reconciles all cases in Clinical Documentation Integrity (CDI) database 80% of the time; determined by quality audit, after training.

Other Functions:

• Work with Clinical Documentation Integrity (CDI) manager, Clinical Documentation Integrity (CDI) educator and team preceptors to learn about proper reviewing procedures selection of primary and secondary diagnoses, and the impact a proper chart revenue contributes to the revenue cycle
• Apply knowledge of health care workflows to work collaboratively with medical staff and other health care team members to improve the overall accuracy and comprehensiveness of medical record documentation, with focus on ensuring accurate reporting of quality outcomes.
• Learn the impact of accurate clinical documentation in the medical record and establishing the Primary Diagnosis
• Meet established operational and productivity standards.
• Learn the use of the Clinical Documentation Integrity (CDI) business platform [3M, PowerChart, Cerner]
• Performs other duties as assigned.
• Ability to perform duties Monday through Friday, 40-hour work week
• Maintain Centra Health policies and procedures, including vaccinations, etc.
• Responsible and accountable for expanding own nursing and Clinical Documentation Integrity knowledge
• Must maintain registered nurse licensure.

Travel Required

Travel is expected to be 0% -10% of the time

Work Environment:

The noise level in the work environment is usually moderate.

The setting for this role will include remote office settings as outlined in Centra Health Home Office policy.

Workplace Exposure:

The normal work routine involves no exposure to blood, body fluids or tissues. Persons who perform these duties are not called upon as part of their employment to perform or assist in emergency medical care or first aid or to be potentially exposed in some other way.

Physical Demands:

While performing the duties of this job, the employee is regularly required to communicate with others. The employee is frequently required to stand, walk, sit, demonstrate hand, and finger dexterity in the course of their work, handle or feel, and reach with hands and arms.  The employee is occasionally required to climb, balance, stoop, kneel, crouch or crawl. Repetive motion may be encountered.

Reasonable accommodation may be made to enable individuals with disabilities to perform their essential duties and responsibilities.

The expected physical workload is expected to be: Sedentary.

Work: Exerting up to 10 pounds of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull or otherwise move objects, including the human body. Sedentary work involves sitting most of the time. Jobs are sedentary if walking and standing are required only occasionally and all other sedentary criteria are met.

This role is expected to use the following machines, tools, and equipment:

• Centra Health Clinical Documentation Integrity Specialist computer equipment

Qualifications

Required Qualifications:

• Registered Nurse in the State of Virginia or compact state
• 5+ years clinical nursing experience, preferably in an intensive clinical nursing environment
• Excellent Computer Skills
• Must past prequalification Clinical Documentation Integrity Specialist test with 85% minimum score.
• Preferred: ACDIS CDI Apprenticeship Certification

Knowledge, Skills, & Abilities

• Must have thorough clinical skills (i.e. working knowledge of pathology, pharmacology, surgical procedures, etc.).
• Excellent written and verbal communication skills.
• Ability to function independently and as a team player in a fast-paced environment.
• Detail-oriented, and relationship building skills.
• Demonstrate and has extensive knowledge of disease pathophysiology.
• Demonstrate ability to use PCs, Microsoft Office suite, and general office equipment (i.e., printers, copy machine, FAX machine, etc.).