Clinical Documentation Specialist-III Inpatient

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MINIMUM QUALIFICATIONS:

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

1. Certification in ONE of the Following:

• Certified Documentation Integrity Practitioner (CDIP) through the American Health Information Management Association (AHIMA)

• Certified Clinical Documentation Specialist (CCDS) through the Association of Clinical Documentation Integrity Specialists (ACDIS)

• Certified Documentation Expert Inpatient (CDEI) through the American Association of Professional Coders (AAPC)

EXPERIENCE:

1. Three (3) years Inpatient acute care coding experience OR

Three (3) years clinical RN experience in Inpatient acute care setting OR

Three (3) of clinical LPN experience in Inpatient acute care setting.

2. Five (5) years of experience in Clinical Documentation Integrity.

CORE DUTIES AND RESPONSIBILITIES: The statements described here are intended to describe the general nature of work being performed by people assigned to this position. They are not intended to be constructed as an all-inclusive list of all responsibilities and duties. Other duties may be assigned.

1. Assists CDI Manager in the planning, execution, and delivery of a high-quality CDI department.

2. Assists CDI Manager in the design, collection, and reporting of relevant data to support the System CDI Program.

3. Collaborates with CDI Educator/Manager for provider educational opportunities.

4. As a CDI system service line expert, responsible for integration and strategic management of service line, keeping the service line team focused on CDI greatest impact.

5. Attends all revenue integrity meetings related to their designated system service line.

6. Capable of efficient review and timely results for focused DRGs and second level reviews.

7. In collaboration with the providers and staff, identifies and records principle diagnoses, secondary diagnoses, procedures, and assigns a working Diagnostic Related Group (DRG).

8. Conducts initial concurrent review and ongoing re-reviews for all selected admissions by documenting findings regarding DRGs, APR-DRGs and Value Based Purchasing/Quality measures.

9. Identifies need to clarify documentation through quality audits in records and initiates communication with physician, nurse, or patient care coordinator by utilizing the appropriate “query” tools in order to capture the documentation in the medical record that accurately supports the patient’s severity of illness.

10. Provides information and ongoing education as necessary to providers and staff on documentation issues, guidelines, and unanswered queries

11. Promotes compliance with CMS, Medicare documentation, and coding and billing regulations.

12. Participates in the processes to assess and improve the services provided and compliance with regulatory requirements. Report results assessment and improvement processes to the appropriate administrative levels.

13. Collaborate with the Quality Department to ensure documentation meets quality initiative standards used for measuring and reporting hospital and provider outcomes.

14. Collects, analyzes and submits timely, accurate and complete reports of clinical documentation information used for measuring and reporting Hospital and Provider outcomes data.

15. Works with the Coding Specialists on any issues that arise concerning documentation, providers, and queries to enhance the concurrent process to enable prompt coding.

16. Serves as a mentor and advises Level I and II CDI Specialists.

PHYSICAL REQUIREMENTS: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. Must be able to sit for long periods of time.

2. Must have visual and hearing acuity within the normal range.

3. Must have manual dexterity needed to operate computer and office equipment.

WORKING ENVIRONMENT: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. Standard office environment.

2. May be exposed to standard patient care environment.

3. Visual strain may be encountered in viewing computer screens, spreadsheets, and other written material.

4. May require travel.

SKILLS AND ABILITIES:

1. Must possess excellent written and verbal communication skills, as well as interpersonal skills necessary to communicate effectively.

2. Must possess the knowledge of related provider healthcare compliance, revenue cycle operations, and auditing techniques required.

3. Must possess the ability to accept mentoring, education and training from others.

4. Must meet quality and productivity standards.

5. Must be able to concentrate and maintain accuracy during constant interruptions.

6. Must possess the ability to prioritize job duties.

7. Must be able to adapt to changes in the workplace and work assignments.

8. Must possess organizational and time management skills.

9. Must possess the knowledge of anatomy, physiology and medical terminology.

10. Must possess analytical and problem-solving skills.

11. Must be proficient in office software programs.

12. Must be able to work independently with minimal supervision.

Additional Job Description:

Remote

Scheduled Weekly Hours:

Shift:

Exempt/Non-Exempt:

Company:

Cost Center: