Clinical Documentation Specialist

Job Description The Clinical Documentation Integrity Specialist (CDI) Educator facilitates improvement system-wide in the overall quality, completeness, and accuracy of medical record documentation through extensive audit investigation, education, and data analysis. A ssists the Clinical Documentation Integrity Specialist (CDI) team in meeting revenue, quality, and productivity goals and objectives by identifying opportunities for continuous quality improvement and knowledge advancement. Conducts regular quality chart reviews to identify educational opportunities within the Clinical Documentation Integrity Specialist (CDI) team and providers to ensure consistency and compliance with state and national standards. Job Description The Clinical Documentation Integrity Specialist (CDI) Educator facilitates improvement system-wide in the overall quality, completeness, and accuracy of medical record documentation through extensive audit investigation, education, and data analysis. A ssists the Clinical Documentation Integrity Specialist (CDI) team in meeting revenue, quality, and productivity goals and objectives by identifying opportunities for continuous quality improvement and knowledge advancement. Conducts regular quality chart reviews to identify educational opportunities within the Clinical Documentation Integrity Specialist (CDI) team and providers to ensure consistency and compliance with state and national standards. Responsibilities Essential Duties and Responsibilities Works with leadership to plan, develop, and implement clinical documentation education programs for Clinical Documentation Integrity Specialist (CDI) staff Educates members of the Clinical Documentation Integrity Specialist (CDI) team on the review functions within the Clinical Documentation Integrity Specialist (CDI) program to meet and maintain enterprise goals and objectives, regulatory compliance, policies and procedures and personnel management Works with program leadership to plan, develop, and implement clinical documentation education programs for Clinical Documentation Integrity Specialist (CDI) staff Analyzes data to ascertain where stronger education is needed for both providers and staff. Mentors and educates Clinical Documentation Integrity Specialist (CDI) staff Works on efforts to improve provider clinical documentation and providing an accurate clinical picture of the patient including severity of illness, risk, and resource utilization. Conducts individual and large group educational sessions for all Clinical Documentation Integrity Specialist (CDI) staff Working closely with the Clinical Documentation Integrity Specialist (CDI) staff, identifies areas of non-specific documentation and improve documentation templates in support of clinical treatment protocols. Collaborate with Clinical Documentation Integrity Specialist (CDI) Manager and other leadership to facilitate the ongoing relevance of department specific orientation content, educational materials and documentation tip sheets and training programs/resources. Assists Clinical Documentation Integrity Specialist (CDI) Manager with the preparation of data and reports to evaluate the effectiveness and overall impact of the clinical documentation improvement program for presentation to Centra Health Leadership and other appropriate oversight committees. Assists with the development and editing of education related policies and procedures and leading and attending Clinical Documentation Integrity Specialist (CDI) team meetings Other Functions Applies 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. Identifies Hospital Acquired Condition (HAC)/Patient Safety Indicator (PSI) query opportunity utilizing resources and follows department guidelines for Hospital Acquired Condition (HAC)/Patient Safety Indicator (PSI) query processes. Comprehends the impact of accurate clinical documentation in the medical record beyond establishing a working Diagnosis Related Group (DRG): accurate billing, public reporting, research data, quality metrics, provider scorecards, accuracy of the Uniform Hospital Discharge Data Set (UHDDS), Case Mix Index (CMI). Demonstrates skills of high efficiency and accuracy to identify and reduce Diagnosis Related Group (DRG) downgrades/denial risks by assuring that clinical support is beyond dispute for Diagnosis Related Group (DRG) integrity, coding, and billing needs. Consistently exceed productivity, quality, and American Health Information Management Association (AHIMA) and Association of Clinical Documentation Integrity Specialists (ACDIS) ethical standards. Proficient and efficient use of the Clinical Documentation Integrity ( CDI) business platform [3M, Power Chart, Cerner, Power Point] Qualifications Required Qualifications Registered Nurse in the State of Virginia or compact state 3 years understanding of Diagnoses Related Group (DRG) assignment and fundamentals of establishing a Diagnoses Related Group (DRG), Primary Diagnosis (PDx) and additional secondary diagnoses and impactful chart aspects. Must have ascertained clinical documentation integrity specialist level three Possess and maintain Certified Clinical Documentation Integrity Specialist (CCDS) status Attend and graduate from Association of Clinical Documentation Integrity Specialist (ACDIS) CDI Educator Boot Camp (online/in person) Knowledge, Skills, & Abilities Must have thorough, up-to-date clinical skills (i.e. current working knowledge of pathology, pharmacology, surgical procedures, etc.) Ability to research, validate and ensure accurate complete information regarding education topics Excellent written and verbal communication skills including presentations. Ability to function independently and as a team player in a fast-paced environment Detail-oriented, and relationship building skills Advanced clinical expertise and extensive knowledge of complex disease processes with a broad clinical experience in an inpatient setting required. A broad knowledge of the disease process, normal/abnormal findings, and reasonable course of treatment, quality measures, and risk management issues is essential. Demonstrated competency in teaching/learning process, organizational skills and computer literacy required. Excellent communication skills and professional demeanor is required Salary Range-$41.20-$59.74/hr. #J-18808-Ljbffr