RN Clinical Documentation Improvement Specialist - Clinical Doc Mgmt Program - FT

RN Clinical Documentation Improvement Specialist

Shift: Day

Position Summary:

Responsible for improving the overall quality and completeness of clinical documentation. Facilitates modifications to clinical documentation through interaction with physicians, nursing staff, other patient caregivers, medical records coding staff to ensure that clinical documentation accurately reflects service rendered to patient. Supports the accuracy and completeness of clinical information used for measuring and reporting physician and medical center outcomes. Provides education to members of the health care team on an ongoing basis using diverse methodology.

Education, License & Cert:

BSN Bachelors Degree: RN; BSN required. Certification in area of specialty is required within 3 years. 3 or more years of CDI experience in an acute care setting along with current CCDS certification may substitute for BSN RN?PA Registered Nurse ? PA: Current Pennsylvania State registered nurse license.

Experience:

Prior CDI experience preferred. Five years recent acute clinical experience in a hospital setting required. Critical care, utilization review or coding experience required. Requires excellent communication skills (both verbal and written), assessment/observation skills, demonstrated analytical thinking, and problem solving skills. Meets minimum score on pre?hire competency test.

Essential Functions:

1. Facilitates modifications to clinical documentation for designated patients to ensure that documentation reflects the level of services rendered which supports proper coding, billing and reimbursement and quality of care outcomes.

Completes admission and continued stay reviews using the CDMP guidelines

Reviews concurrent documentation from all disciplines to capture best practice quality indicators

Conducts follow?up reviews of clinical documentation to ensure points of clarification have been recorded in the patient's chart.

Completes reviews in a timely manner as outlined in CDMP guidelines.

2. Demonstrates knowledge of CDMP guidelines and program, DRG payor issues, documentation opportunities, clinical documentation requirements, and referral policies and procedures.

Collaborates with hospital quality team, case managers and coding specialists.

Clarifies questions with other coder specialists and/or department manager.

Educates internal customers on compliant documentation opportunities, coding and reimbursement issues, as well as performance improvement methodologies.

Reviews clinical issues with coding staff to assign a working DRG.

3. Utilizes CDMP software/computer applications.

Updates worksheets to reflect any changes in status, procedures/treatments, and conferring with physicians to finalize diagnoses and quality measures.

Assists with management of CDMPTrak and reporting as designated.

Assists with special projects as requested.

4. Facilitates teamwork and performance improvements in the organization.

Communicates in a positive and productive manner.

Promotes growth and education of others by sharing knowledge and resources.

Works collaboratively with other department staff and physicians.

Participates in performance improvement activities.

Maintains minimum 8 hrs continuing education per year

Other Duties:

It is understood that this description is not intended to be all inclusive, and that other duties may be assigned as necessary in the performance of this position.