Clinical Documentation Improvement Specialist

Clinical Documentation Improvement Specialist

At White Plains Hospital, you have an opportunity to work side-by-side with some of the most talented people in the world.

We have been widely recognized for our exceptional culture, world-class physicians, Magnet-designated nurses and passionate employees who make a real difference in our community. With tremendous growth opportunities, great benefits, and flexible work schedules, it is no wonder why we are consistently recognized as a Great Place to Work.

Position Summary

The Clinical Documentation Improvement Specialist (CDIS) facilitates accurate documentation for severity of illness and quality in the medical record. This involves extensive record review, interaction with physicians, health information management professionals, and nursing staff. Active participation in team meetings and education of staff in the Clinical Documentation Improvement Program (CDIP) process is a key role.

Essential Functions and Responsibilities Includes the Following:

1. Understands and adheres to the WPH Performance Standards, Policies and Behaviors.
2. Reviews the medical record for completeness and accuracy for severity of illness (SOI) and quality using the current CDI software and electronic medical record.
3. Performs accurate and timely initial and concurrent record review
4. Recognize opportunities for documentation improvement
5. Facilitates appropriate clinical documentation to support accurate diagnosis coding and to ensure the level of service rendered to all patients is recorded.
6. Formulate clinically credible documentation clarifications (queries) to improve clinical documentation and capture of the appropriate principal diagnosis and all comorbidities.
7. Request documentation clarifications as appropriate for principal diagnosis, severity of illness, risk of mortality, risk adjustment and quality measures.
8. Communicates with physicians, nurse practitioners, case managers, coders and other members of the care team to facilitate comprehensive medical record documentation.
9. Timely follow up on all cases and resolution of those with clinical documentation clarifications.
10. Collaborate with HIM coding staff to promote complete and accurate clinical documentation and resolve discrepancies and appropriate DRG assignment.
11. Communicates with coders and resolves discrepancies
12. Conducts post discharge reviews and reconciliation of queries.
13. Performs all other related duties as assigned.

Education & Experience Requirements

1. PA or RN required.
2. Current professional license required
3. RNs must be a graduate from an accredited school of nursing with current New York RN license/registration.
4. BSN Required for RNs hired after 1/1/18.
5. All RNs hired before 1/1/18 will be required to have their BSN (or MSN) by 12/31/21.
6. Proof of BSN (or MSN) must be received by Human Resources by 12/31/21 for verification.
7. Current state Registered Nurse license
8. Score (minimum of 70%) on the Clinical Competency Assessment (CCA)

Experience:

5 years of adult acute care experience in med/surg, critical care, emergency room, or PACU.

Core Competencies

• Organizational, analytical, writing and interpersonal skills
• Dependable, self-directed and pleasant
• Critical thinking, problem-solving and deductive reasoning skills
• Knowledge of Pathophysiology and Disease Process
• Basic Computer skills – familiarity with Windows-based software programs
• Knowledge of disease processes in all clinical specialties; anatomy & physiology and pharmacology and must have the ability to correlate abnormal lab results to disease processes.
• Knowledge of official coding guidelines and documentation requirements related to the Inpatient Prospective Payment System
• Knowledge of regulatory environment
• Understand and communicate differences between Medicare Part A and Part B guidelines and how they impact DRG assignments
• Knowledge of Coding Guidelines & Quality Measures

Physical/Mental Demands/Requirements & Work Environment

• May be exposed to chemicals necessary to perform required tasks. Any hazardous chemicals the employee may be exposed to are listed in the hospital's SDS (Safety Data Sheet) database and may be accessed through the hospital's Intranet site (Employee Tools/SDS Access). A copy of the SDS database can also be found at the hospital switchboard, saved on a disc.
• Must be able to alternate between remaining stationary at the work station and walking to patient units.
• Constantly utilizes/operates computer to access information.
• Must be able to utilize multiple screens to view and document.
• Flexible and able to adapt to changes.

Primary Population Served

Check appropriate box(s) below:

Neonatal (birth – 28 days) - Patients with exceptional communication needs

Infant (29 days – less than 1 year) - Patients with developmental delays

Pediatric (1 – 12 years) - Patients at end of life

Adolescent (13 – 17 years) - Patients under isolation precautions

Adult (18 – 64 years) - Patients with cultural needs

Geriatric (> 65 years) - All populations

Bariatric Patients with weight related comorbidities - Non-patient care population

The responsibilities and tasks outlined in this job description are not exhaustive and may change as determined by the needs of White Plains Hospital.

Salary: $95,373.14- $143,059.41