Clinical Documentation Improvement Specialist

EQUAL EMPLOYMENT OPPORTUNITY

• Race, color, religion or belief, national, social or ethnic origin, sex (including pregnancy), age, physical, mental or sensory disability, HIV Status, sexual orientation, gender identity and/or expression, marital, civil union or domestic partnership status, past or present military service, family medical history or genetic information, family or parental status, or any other status protected by the laws or regulations in the locations where we operate shall not be a factor in employment for this position. Due to the nature of hospital services, it may become necessary to work extended hours.

POSITION SUMMARY

 

The Clinical Documentation Improvement (CDI) specialist is responsible for facilitating the improvement in the overall quality and completeness of provider-based clinical documentation in the medical record. This onsite position will be responsible for assisting treating providers to ensure that documentation in the medical record accurately reflects the severity of illness of the patient as well as the level of services rendered. The CDI Specialist assesses clinical documentation through extensive review of the medical record, interaction with physicians, nursing staff, other patient care givers, and Health Information Management (HIM) coding staff to ensure that appropriate reimbursement is received for the level of services rendered to patients, and the clinical information utilized in profiling and reporting outcomes is complete and accurate.

POSITION SUPERVISORY RESPONSIBILITIES

• Reports To:
• Coding/CDI Manager, Health Information Management
• Supervises:
• None

POSITION REQUIREMENTS

• Minimum Education
• Associates degree
• Minimum Work Experience
• Three (3) years or more experience in medical record data abstraction related to coding, quality monitoring, or clinical documentation improvement.
• Required Licenses/Certifications
• RN license
• Required Skills, Knowledge, and Abilities
• Excellent communication, interpersonal, collaboration and customer relations skills. Ability to analyze data for patterns and trends. Strong critical thinking skills and ability to integrate knowledge. Prioritization and organizational skills. Working knowledge of Medicare reimbursement system, coding structures, medical necessity criteria preferred, but not required
• Preferred Qualification
• CDIP, CCDS, RHIT or RHIA credentials
•  

PHYSICAL REQUIREMENTS

 

Primarily sedentary working reviewing records and keying information using a computer monitor and keyboard. Ability to concentrate and read for long periods of time. Quiet surrounding with adequate lighting

 

QUALITY BEHAVIORAL EXPECTATIONS

Generally and in all job specific duties: Uses critical thinking skills to determine evidence based solutions. Systematically gathers and reviews pertinent information to prevent errors (PDCA -- Plan, Do, Check, Act). Pursues individual or team learning and growth opportunities to continually build skills. Understands and abides by all safety regulations.

 

SERVICE EXCELLENCE BEHAVIORAL EXPECTATIONS

• Generally and in all job specific duties: Maintains patient confidentiality. Rounds regularly with patients, direct reports and/or customers. Uses telephone and elevator etiquette. Acts as an employee ambassador. Committed to know hospital service lines and shows pride in our organization. Uses AIDET when dealing with internal or external customers.

 

FISCAL RESPONSIBILITY BEHAVIORAL EXPECTATIONS

• Generally and in all job specific duties: Takes responsibility for solving problems. Treats company resources responsibly. Performs work functions timely and accurately. Respects our environment; keeps public areas neat and clean and returns supplies to the appropriate areas.

 

PEOPLE BEHAVIORAL EXPECTATIONS

Generally and in all job specific duties: Supports the team through good attendance. Maintains a