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 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). Works with Medical Director, HIM to collaborate with the medical staff to ensure timely completion of physician clarifications to capture appropriate documentation. Maintains strict adherence to patient confidentiality according to MHS standards and regulatory requirements. Reviews inpatient electronic medical records and constructs compliant provider clarifications to ensure that patient documentation reflects appropriate severity of illness and risk of mortality. 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. Generates CDI reports to monitor expected provider clarification and response rates, impact on case mix index (CMI) and reimbursement as appropriate. Conducts follow‑up reviews of clinical documentation to ensure issues discussed and clarified with the physician have been recorded in the patient’s chart. 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. Performs all duties as requested. 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). 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. Additional Information Registered RN or Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA) or Certified Coding Specialist (CCS). In nursing or graduate of an accredited school of HIM. Equal Opportunity Employment 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, sexual orientation, national origin, veteran status, disability, genetic information, or any factor prohibited by law. #J-18808-Ljbffr