Clinical Documentation Specialist I

Overview

Embark on a rewarding career with Delray Medical Center hospital. If you are a compassionate healthcare professional eager to contribute to patient care, this is your opportunity where your skills make a difference every day. Join us in delivering exceptional healthcare with a personal touch.

At Delray Medical Center, we understand that our greatest asset is our dedicated team of professionals. That’s why we offer more than a job – we provide a comprehensive benefit package that prioritizes your health, professional development, and work-life balance. The available plans and programs include:

• Medical, dental, vision, and life insurance
• 401(k) retirement savings plan with employer match
• Generous paid time off
• Career development and continuing education opportunities
• Health savings accounts, healthcare & dependent flexible spending accounts
• Employee Assistance program, Employee discount program
• Voluntary benefits include pet insurance, legal insurance, accident and critical illness insurance, long term care, elder & childcare, auto & home insurance

Note : Eligibility for benefits may vary by location and is determined by employment status

Job Summary

Full Time, Days

The Clinical Documentation Specialist (CDI) I, reports to the Market Clinical Documentation Specialist Manager. Under limited direction works collaboratively with medical, nursing and ancillary staff, and case managers and coders to improve the overall accuracy, quality and completeness of clinical documentation in accordance to clinical documentation guidelines and established policies/procedures. The CDI will be responsible for performing initial and follow up reviews of selected patient accounts both while hospitalized or after discharge to identify appropriate documentation accuracy and identify gaps and opportunities to reflect the level of service rendered to all patients. Ensures the accuracy and completeness of clinical information used for measuring and reporting quality services and performance of specific quality outcomes. Oversees clinical documentation patterns and trends to identify areas of improvement in documentation and performance measures. Educates all members of the patient care team regarding clinical documentation needs, changes to clinical documentation guidelines, coding and reimbursement issues, and quality performance documentation requirements on an on-going basis. Develops and conducts on-going Performance Documentation education for new staff including case managers, coders, physicians, residents, nursing and allied health professionals. Compiles, analyzes, and evaluates quality and clinical data collected as part of an integrated system-wide program of clinical improvement and documentation requirements. Provide full CDI coverage to the designated facility as per the CDI Department guidelines and directions.

Responsibilities

1. Facilitates appropriate clinical documentation to support appropriate diagnosis coding and to ensure the level of service rendered to all patients is recorded.
2. Collaborates with HIM coding staff to promote complete and accurate clinical documentation and correct negative trends.
3. Communicates with physicians, nurse practitioners, case managers, coders and other members of the care team to facilitate comprehensive medical record documentation to reflect treatment, decision-making and medical documentation.
4. Assigns a working MS/APR-DRG and severity level using coding rules and guidelines with follow up reviews as required by LOS standards.
5. Analyze clinical information to identify areas within the chart for potential gaps in physician documentation.
6. Queries physicians on a concurrent basis. Works with physicians to clarify documentation in the medical record.
7. Formulate credible clinical documentation clarifications to improve clinical documentation of principal diagnosis, co-morbidities, present on admission (POA), quality core measures, and patient safety indicators (PSI).
8. Conducts post discharge reviews for comparative analysis of CDI Specialist and HIM MS/APR-DRG and severity level assignment. Reviews clinical issues with the coding staff to assign a working DRG.
9. Develops and conducts ongoing education for new staff, including new CDI Specialists, physicians and nursing.
10. Utilizes software systems (including APR-DRG encoder) to collect, track, and report outcomes. Requires proficiency in abstracting and data entry into all databases used for clinical documentation. Maintains integrity of data collection.
11. Participates in ongoing education of staff. Develops educational material and tools relative to documentation improvement practices for individual practitioners and groups of clinicians presented as handouts, PowerPoint, etc.

Qualifications

EDUCATION / EXPERIENCE

Required:

• Graduate from an accredited School of Nursing with RN or LPN, BSN or
• Graduate from an accredited School of Medicine with MD or MBBS (either foreign or domestic),
• And have minimum of 1-year experience working as a CDI in an acute care hospital.

Preferred:

• Graduate from an accredited Health Informatics program for clinical Documentation
• 1 – 2 -years’ experience or more working as a CDI in an acute care hospital
• 3 - years’ experience or more in a clinical setting with patient care

REQUIRED CERTIFICATIONS/LICENSURE

Required:

• Either RN, or LPN with an active license
• Or MD, or MBBS

Preferred:

• BSN
• CDI related certificate (RHIA, RHIT, CCS, CDIP, CCDS)
• USMLE Certificate

KNOWLEDGE, SKILLS, ABILITIES

Required:

• Analytical ability and comprehensive knowledge base to gather and interpret clinical documentation data, to identify discrepancies, problems or issues, and to determine methods for ensuring compliance with clinical documentation policies and procedures. Ability to analyze data for patterns and trends.
• Strong critical thinking skills and ability to integrate knowledge. Excellent observation, communication and decision-making abilities. Strong presentation skills in order to articulate the program to physician and other health care professionals in order to educate and teach clinical documentation requirements and educate all members of the care team.
• Ability to prioritize work, focus on completion of tasks and meet deadlines through strong organizational skills. cope with stressful situations, manage multiple and sometimes conflicting priorities simultaneously. Demonstrates motivation and can work as a focused, self-directed individual.
• High-level communication skills both verbal and written. Ability to collaborate and use assertive interpersonal skills to discuss clinical documentation issues and work effectively with all levels of internal personnel such as coders, physicians, nursing and allied health professionals.
• Demonstrated team player skills and encourage a spirit of cooperation among CDI team, clinicians, coders, physicians, etc., and direct others toward objectives that contribute to the success of the program.
• Knowledge of clinical documentation guidelines, policies and procedures, and the requirements of compliant query and communication with clinicians.
• Strong computer skills and knowledge of Email, Microsoft Word, Microsoft Excel or other software packages including database and spreadsheet programs.

Preferred:

• Demonstrated leadership skills
• Have experience working with Iodine, 3M encoder, Artifact or Cerner-PowerChart
• Skilled in conflict resolution

EXPERIENCE

Organization Description

Delray Medical Center, part of the Palm Beach Health Network, is a 536-bed acute care hospital spanning 30 acres, employing over 1,700 employees, 700 physicians and serving southern Palm Beach County for over 40 years. As both a community hospital and state-designated Level I Trauma Center, Delray Medical Center offers several specialized services including advanced cardiac and vascular facilities, orthopedics, neurosciences, emergency care and weight-loss surgery. Pinecrest Rehabilitation and Outpatient Hospital at Delray Medical Center is the only state designated brain and spinal cord injury rehabilitation program in the county by the State of Florida. Delray Medical Center is also home to Fair Oaks Pavilion, a 53-bed adult psychiatry unit. Come join one of our many teams!

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