Clinical Documentation Integrity Specialist - HIM - FT - Days - MSS - Hybrid Eligible

Location Miramar, Florida Summary Facilitates improvement in the overall quality, completeness and accuracy of medical record documentation to ensure that the patient’s acuity of care and severity of illness are accurately reflected in the medical record. Obtains appropriate clinical documentation through extensive interaction with physicians, nursing staff, other patient caregivers, and Health Information Management coding staff to ensure that clinical documentation is complete and accurate. Educates all members of the patient care team on documentation guidelines on an ongoing basis. Reviews electronic medical records to construct compliant provider documentation clarifications. Responsibilities Provides ongoing, one‑on‑one, or group education related to documentation integrity and compliance to physicians, extenders, nursing, clinical dieticians, wound care specialists, physical therapists and other allied health professionals. Collaborates with Auditor, Clinical Documentation Integrity (CDI) Compliance for education topics for staff training. Reviews inpatient electronic medical records and constructs compliant provider clarifications to ensure that patient documentation reflects appropriate severity of illness and risk of mortality. Maintains strict adherence to patient confidentiality according to MHS standards and regulatory requirements. Works with Medical Director, HIM to collaborate with the medical staff to ensure timely completion of physician clarifications to capture appropriate documentation. Assigns and updates appropriate working DRG, diagnoses and procedures during initial and continued stay record reviews. Collaborates with Quality Management and Population Health specialists to advise of Patient Safety Indicators (PSIs), Hospital Acquired Conditions (HACs) and Bundled Payments for Care Improvement (BPCI) admit diagnoses/Diagnosis Related Groups (DRGs). Performs all duties as requested. Collaborates with coding staff to review patient’s clinical presentation/disease process, coder posed provider clarifications, and seeks guidance related to coding guidelines and assigned DRG. Conducts follow‑up reviews of clinical documentation to ensure issues discussed and clarified with the physician have been recorded in the patient’s chart. Generates CDI reports to monitor expected provider clarification and response rates, impact on case mix index (CMI) and reimbursement as appropriate. Competencies ACCOUNTABILITY, ACCURACY – CDI, CUSTOMER SERVICE, EFFECTIVE COMMUNICATION, HEALTH INFORMATION MANAGEMENT (HIM) SYSTEMS – SPECIALISTS, HUMAN ANATOMY – CLINICAL DOC, MEDICAL CODING (CDI), MEDICAL TERMINOLOGY (2), PROBLEM SOLVING, PRODUCTIVITY – CDI, RESPONDING TO CHANGE, STANDARDS OF BEHAVIOR Education and Certification Requirements Accredited Program (Required)Registered Nurse Compact License (RN LICENSE COMPACT) – Compact RN Multistate, Registered Nurse License (RN LICENSE) – State of Florida (FL) Additional Job Information Complexity of Work: Requires critical thinking skills, effective communication skills, decisive judgment and the ability to work with minimal supervision. Must be able to work in a stressful environment and take appropriate action. Proficient in basic computer skills including Microsoft office applications, computerized encoder software and electronic medical record system. Ability to work well with physicians and other allied health staff. Required Work Experience: RN with two (2) years of clinical nursing experience or RHIA/RHIT with two (2) years inpatient coding experience or CCS with two (2) years inpatient coding experience. Other Information: Registered RN or Registered Health Information Technician (RHIT) or Registered Health Information Administrator (RHIA) or Certified Coding Specialist (CCS). Additional Education Info: in Nursing or graduate of an accredited school of HIM. Additional Credential Info: Can be an RN or Registered Health Information Technician (RHIT) or Registered Health Information Administrator (RHIA) or Certified Coding Specialist (CCS). Working Conditions and Physical Requirements Bending and Stooping = 60% Climbing = 0% Keyboard Entry = 60% Kneeling = 40% Lifting/Carrying Patients 35 Pounds or Greater = 0% Lifting or Carrying 0 - 25 lbs Non-Patient = 40% Lifting or Carrying 2501 lbs - 75 lbs Non-Patient = 0% Lifting or Carrying > 75 lbs Non-Patient = 0% Pushing or Pulling 0 - 25 lbs Non-Patient = 60% Pushing or Pulling 26 - 75 lbs Non-Patient = 60% Pushing or Pulling > 75 lbs Non-Patient = 0% Reaching = 40% Repetitive Movement Foot/Leg = 40% Repetitive Movement Hand/Arm = 60% Running = 0% Sitting = 60% Squatting = 40% Standing = 60% Walking = 60% Audible Speech = 60% Hearing Acuity = 60% Smelling Acuity = 0% Taste Discrimination = 0% Depth Perception = 60% Distinguish Color = 60% Seeing - Far = 60% Seeing - Near = 60% Bio hazardous Waste = 0% Biological Hazards - Respiratory = 0% Biological Hazards - Skin or Ingestion = 0% Blood and/or Bodily Fluids = 0% Communicable Diseases and/or Pathogens = 40% Asbestos = 0% Cytotoxic Chemicals = 0% Dust = 40% Gas/Vapors/Fumes = 0% Hazardous Chemicals = 0% Hazardous Medication = 0% Latex = 0% Computer Monitor = 60% Domestic Animals = 40% Extreme Heat/Cold = 0% Fire Risk = 0% Hazardous Noise = 0% Heating Devices = 0% Hypoxia = 0% Laser/High Intensity Lights = 0% Magnetic Fields = 0% Moving Mechanical Parts = 0% Needles/Sharp Objects = 0% Potential Electric Shock = 0% Potential for Physical Assault = 0% Radiation = 0% Sudden Decompression During Flights = 0% Unprotected Heights = 0% Wet or Slippery Surfaces = 40% Shift Primarily for office workers - not eligible for shift differential Disclaimer This job description is not intended, nor should it be construed to be an exhaustive list of all responsibilities, skills, efforts or working conditions associated with the job. It is intended to indicate the general nature and level of work performed by employees within this classification. EEO Statement Memorial Healthcare System is proud to be an equal opportunity employer committed to workplace diversity. Memorial Healthcare System recruits, hires and promotes qualified candidates for employment opportunities without regard to race, color, age, religion, gender, gender identity or expression, sexual orientation, national origin, veteran status, disability, genetic information, or any factor prohibited by law. We are proud to offer Veteran’s Preference to former military, reservists and military spouses (including widows and widowers). You must indicate your status on your application to take advantage of this program. Employment is subject to post offer, pre‑placement assessment, including drug testing. Contact If you need reasonable accommodation during the application process, please call View phone number on click.appcast.io (M-F, 8am-5pm) or email View email address on click.appcast.io #J-18808-Ljbffr Dormont Manufacturing Co