HIM CDI Specialist, Remote

Clinical Documentation Specialist

This position is responsible for reviewing patient medical records to facilitate modifications to clinical documentation through concurrent (pre-bill) interaction with providers and other members of the healthcare team to promote accurate capture of clinical severity of illness and risk of mortality (later translated into coded data) and to support the level of service rendered to relevant patient populations. CDIS exhibits expert knowledge of clinical documentation requirements, MS-DRG Assignment, case mix index (CMI) analysis, clinical disease classifications, major and non-major complications and comorbidities (MCCs or CCs), and quality-driven patient outcome indicators. Interacts as needed with internal customers to include but not limited to hospital staff, physicians, and other revenue cycle team members. Actively participates in department and hospital performance initiatives when needed to ensure ULH success.

Responsibilities

• Completes initial medical record reviews of all inpatient patient accounts (all payers) within 24-48 hours of admission for a specified patient population to:
• Evaluate and review inpatient medical records daily, concurrent with patient stay, to identify opportunities to clarify missing or incomplete documentation.
• Assign the principal diagnosis, pertinent secondary diagnoses, procedures for accurate MS-DRG assignment, score risk of mortality and severity of illness and initiate a review worksheet.
• Conduct follow-up reviews of patients every 2-3 days to support and assign a working or final MS-DRG assignment upon patient discharge, as necessary.
• Formulate clinically, compliant and credible physician queries regarding missing, unclear or conflicting health record documentation by requesting and obtaining additional documentation within the health record, as necessary.
• Proactively collaborate with physicians to discuss and clarify documentation inconsistencies to ensure accuracy of the medical record and appropriate capture of the course of treatment provided to the patient.
• Educate providers about identification of disease processes that reflect SOI, complexity, and acuity to facilitate accurate application of code sets.
• Gather and analyze information pertinent to documentation findings and outcomes, and use this information to develop action plans for process improvements.
• Collaborate with case managers, nursing, and other ancillary staff regarding interaction with physicians concerning documentation opportunities and to resolve physician queries prior to discharge.
• CDIS communicates/completes Clinical Documentation Improvement (CDI) activities and coding issues (lacking documentation, physician queries, etc.) for appropriate follow-up and resolution with appropriate leadership.
• Remain abreast and current on training of new hires and ongoing CDIS professional staff development as well as participate in CDI-related continuing education activities to maintain certifications and licensures.
• Collaborate with HIM/coding professionals to review and resolve DRG mismatches for individual problematic cases and ensure accuracy of final coded data in conjunction with CDI managers, coding managers, and/or physician advisors.
• Identify patterns, trends, variances, and opportunities to improve documentation review processes.
• Aid in identification and proper classification of complication codes and present on admission (POA) determination (patient safety indicators/hospital-acquired conditions) by acting as an intermediary between coding staff and medical staff.
• Contribute to a positive working environment and perform other duties as assigned or directed to enhance the overall efforts of the organization.

Qualifications

• CDIS candidate must have and maintain current licensure as a RN, RHIA, RHIT or possess an active CCS (AHIMA) or CPC-H (AAPC) coding credential.
• CDIS must have 3+ years of acute care experience as a RN or 3+ years inpatient coding experience as a RHIA/RHIT/CCS/CPC-H.
• Must have advanced clinical expertise and extensive knowledge of complex disease processes with broad clinical experience in an inpatient setting.
• Certified Clinical Documentation Specialist or Clinical Documentation Improvement Professional (CCDS or CDIP) credential is required within 12 months of employment.

KNOWLEDGE, SKILLS, & ABILITIES

• Working knowledge of medical terminology and Official Coding Guidelines.
• Ability to work independently, self-motivate, and adapt to the changing healthcare arena
• Excellent verbal and written communication skills, analytical thinking, and problem solving with strong attention to detail
• Proficiency in organizational skills and planning, with an ability multitask in a fast-paced environment
• Proficiency in computer use, including database and spreadsheet analysis, presentation programs, word processing, and Internet research
• Working knowledge of federal, state, and private payer regulations as well as applicable organizational policies and procedures
• Working knowledge of quality improvement theory and practice, core measures, safety, and other required reporting programs
• Ability to formulate clinically, compliant and credible physician queries