Clinical Documentation Improvement Specialist - Clinical Performance - FT - Day

Position Status:

Full time

Shift:

First Shift (Days - Less than 12 hours per shift) (United States of America)

Hours per week:

40

Job Information
Exemption Status: Non-Exempt

A Brief Overview
The CDIS/HCC RN uses their expert knowledge of clinical care and applicable coding guidelines to facilitate modifications to clinical documentation in the electronic medical record through concurrent (pre-bill) interaction with providers and other members of the healthcare team. He or she promotes complete and accurate diagnostic and procedural coded data to facilitate accurate reimbursement, clinical severity (severity of illness and risk of mortality), constructive financial and strategic planning, and physician profiling to support the level of service rendered to relevant patient populations. This includes hospital, specialty, and physician quality of care, as well as patient safety and outcome measures.

Education Qualifications

• Bachelor's Degree Bachelor's of Science in Nursing (BSN) Preferred

Experience Qualifications

• 3 years Clinical experience in an acute care setting. Required

Skills and Abilities

• Advanced clinical expertise and extensive knowledge of age-specific needs and the elements of complex disease processes and related procedures with broad clinical experience in a direct patient care setting and the related medical record documents. Must possess excellent communication, collaboration, and critical thinking skills. Ability to work independently in a time oriented environment. (Required proficiency)
• The staff nurse functions primarily in the role of care manager and assumes role/responsibilities for directing and overseeing the care team. As identified in the Kansas State Nurse Practice Act and Joint Commission regulations, RNs have as their underlying role/responsibilities: coordination of patient care activities, delegation of specified care team members, supervision of team members and evaluation of patient response to care provided. (Required proficiency)

Licenses and Certifications

• Registered Nurse - KSBN Required
• Certified Clinical Documentation Specialist - CCDS • Certified Clinical Documentation Specialist (CCDS) through the Association of Clinical Documentation Improvement Specialist (ACDIS) or Certified Risk Adjustment Coder (CRC) Preferred

What you will do

• Review medical records on an on-going basis to identify opportunities to clarify missing or incomplete documentation.
• Collaborate with providers, case managers, coders, and other healthcare team members to facilitate comprehensive health record documentation that reflects clinical treatment, decisions, diagnoses, and interventions.
• Utilize the hospital’s designated clinical documentation system to conduct reviews of the health record and identify opportunities for clarification.
• Conduct follow-up of posted queries to ensure that queries have been answered and physician responses have been appropriately documented.
• Provide, coordinate and participate in education related to compliance, coding, and clinical documentation issues within the healthcare organization. This may include rounding with the multidisciplinary healthcare team.
• Act as a consultant to coding professionals when additional information or documentation is needed to assign coded data.
• Collaborate with HIM/coding professionals to review individual problematic cases and ensure accuracy of final coded data and continuous self-evaluation in conjunction with the manager, coding manager, and/or physician advisors; discusses any issues or concerns with the manager.
• Gather and analyze information pertinent to documentation findings and outcomes and share with the CDI/HCC and coding teams.
• Conduct independent research and education to promote knowledge of clinical topics, coding guidelines, regulatory policies and trends, and healthcare economics.
• Enhance expertise in query development, presentation, and standards (including understanding of published query guidelines and practice expectations for compliance).
• Participate in related continuing education activities to maintain certifications and licensures.
• Contribute to a positive working environment and perform other duties as assigned or directed to enhance the overall efforts of the organization.

Required for All Jobs

• Complies with all policies, standards, mandatory training and requirements of Stormont Vail Health
• Performs other duties as assigned

Patient Facing Options

• Position is Not Patient Facing