Clinical Documentation Specialist

Role Overview

Meet CDI program objectives, goals, and balance scorecard metrics.

Ensures timely, accurate, and complete documentation of clinical information used for measuring and reporting physician and hospital outcomes.

Ensure effective communications with key stakeholders.

Analyzes data, creates reports to meet desired outcomes.

Identifies trends and opportunities for improvement in clinical documentation.

Meets program quality and productivity guidelines and standards.

Collaborates with coding professionals to fully support the needs of clinical code assignment, communicates proficiently with coding professionals to resolve identified discrepancies.

Work effectively with CDI team members to accomplish departmental goals.

Demonstrates continued advancement in professional growth.

Position Type / Expected Hours of Work

This is a full-time position. Days and hours of work are generally Monday through Friday, 8:00 a.m. to 5 p.m. This position occasionally requires long hours and weekend work.

Travel

Minimal travel required; up to 5%

Required Education and Experience

• Experience: Bachelor’s degree in healthcare field (e.g., nursing, health information management) OR equivalent combination of education/experience combined required. (One year of education equals one year of experience).
• Minimum Experience: Minimum of one to three years’ experience in clinical quality, utilization management, case management, nursing, coding, or a related field.
• Preferred Experience: Three to five years’ experience in a Clinical Documentation Improvement Program with previous experience in clinical quality, utilization management, case management, nursing, coding, or related field (e.g., physician) of which a minimum of three years’ experience is in a management or supervisory role.
• Education: Bachelor’s degree, with a healthcare related credential

Additional Eligibility Qualifications

None required

Security Access Requirements

In addition to the specific security access required by the employee’s client engagement, the employee will have access to the Omega systems set forth in "Standard Field Employee” profile.

ADP: Standard Employee Level Access

Omega Healthcare is an Equal Employment Opportunity employer. All qualified applicants will receive consideration for employment without regard to their race, color, religion, national origin, gender, age, sexual orientation, gender identity or expression, marital status, mental or physical disability, protected veteran status, and genetic information, or any other basis protected by applicable law. Omega Healthcare also prohibits harassment of applicants or employees based on any of these protected categories.

Omega Healthcare makes reasonable accommodations when needed for applicants and candidates with disabilities or religious observances. If reasonable accommodation is needed to participate in the job application, interview, or any other part of the hiring process, please contact Human Resources at View email address on click.appcast.io.

Required Experience

• 5 Years of bedside Clinical Nursing experience in Adult Intensive Care Unit, Critical Care Unit, or Medical Surgery Unit.
• Active RN license in the states of IA, WI, IL, or SD or Compact US Nursing License.
• 2 Years of concurrent experience in Clinical Documentation Integrity working with Concurrent Chart Review.
• 2 Years of Epic Experience.
• 2 Years of experience writing providers queries.
• Resume must reflect all required experience.

Preferred Experience

• Experience with Nuance CDE a plus.

Operational

Conducts reviews of designated medical records to facilitate the creation of a health record that accurately represents the acuity of the patient’s illness and the resources used to treat the patient by ensuring provider documentation supports all applicable diagnosis codes.

Ensures assignment of the working DRG is supported by diagnostic and procedural findings from the medical record. This will include the identification of secondary diagnosis that may result in Complications and Co‑morbidities (CC) and/or Major Complications and Co‑morbidities (MCC) assignment.

Utilizes a compliant query process per guidelines and policies and follows each query through closure including complete documentation of ongoing follow up and communication.

Maintains integrity and compliance of medical record reviews, clinical documentation integrity documentation, and queries.

Efficiently and effectively utilizes UnityPoint Health’s selected CDI software and processes (i.e. CDI worksheet and workflow, physician query, query and DRG reconciliation processes).

Meets the minimum productivity and quality assurance standards established by the CDI department.

Relationship Building/Collaboration

Collaborates with coding staff and leaders for improved knowledge and understanding of coding guidelines.

Collaborates with physicians and/or other hospital staff to coordinate work and resolve issues.

Collaborates with Clinical Documentation Integrity leaders to provide feedback and receive work direction.

Collaborates with other hospital departments as needed and directed by CDI leaders.

Required Skills

• CDI
• CDI - Setting - ICU
• CDI - Skill - Communication Skills
• CDI - Skill - Written Query Skills
• System - Microsoft - Excel
• System - Microsoft - PowerPoint
• System - Microsoft - Word
• Systems - 3M CDI

Benefits

We offer a comprehensive benefits package that may include health, dental, and vision coverage, voluntary insurance options, a 401(k) plan with employer match, professional development opportunities, paid time off, and holiday pay. Eligible employees may also have the opportunity to participate in bonus programs, commissions, or other variable incentive plans. Benefits and incentive eligibility may vary based on position, location, and tenure.

AAP/EEO Statement

Omega Healthcare is an Equal Employment Opportunity employer. All qualified applicants will receive consideration for employment without regard to their race, color, religion, national origin, gender, age, sexual orientation, gender identity or expression, marital status, mental or physical disability, protected veteran status, and genetic information, or any other basis protected by applicable law. Omega Healthcare also prohibits harassment of applicants or employees based on any of these protected categories.

Omega Healthcare makes reasonable accommodations when needed for applicants and candidates with disabilities or religious observances. If reasonable accommodation is needed to participate in the job application, interview, or any other part of the hiring process, please contact Human Resources at View email address on click.appcast.io.