Clinical Documentation Improvement Specialist
|Title and dept.|
|Clinical Documentation Improvement Specialist||Health Information Management|
The Clinical Documentation Improvement Specialist reviews and analyzes health records to identify relevant diagnoses and procedures for distinct patient encounters. The CDI Specialist will identify potential DRG (diagnosis related groups) assignment based on documentation and clinical indicators to improve the quality of documentation ensuring compliance with State and Federal regulations. The data obtained from health record review and analysis is utilized for reimbursement purposes, in the assessment of clinical care, and to support the ongoing education of the health care team, including physicians, allied health professionals, nursing, and case management. The CDI Specialist facilitates and obtains physician documentation for any clinical conditions or procedures to support the appropriate severity of illness, expected risk of mortality, and complexity of care of the patient. The CDI Specialist supports timely, accurate, and complete documentation of clinical information used for measuring and reporting physician and facility outcomes. In addition, the CDI Specialists assists HIM coders with education, training, and daily needs such as report monitoring, coding query writing, and internal coding audits.
-The specialist must have a high school diploma or the equivalent.
-The specialist must have had training in medical terminology, anatomy, and physiology.
-The specialist must have a nursing degree.
Licensure: The specialist must hold an RN certification and preferably possesses a CCS licensure.
-The specialist should possess in-depth knowledge of medical record content.
-The specialist should possess knowledge of coding/classification systems appropriate for inpatient, outpatient, and emergency care, specifically ICD-10-CM and CPT.
-The specialist should possess clinical knowledge.
-The specialist should have basic computer knowledge.
-The specialist should be knowledgeable of use of coding software.
•-Requires excellent observation skills, analytical thinking, problem solving, plus excellent verbal/ written and presentation skills.
-Must have the ability to balance and juggle multiple tasks, projects and requests; meet deadlines.
-Manuel and finger dexterity.
-Sitting for extended periods of time.
-Ambulate to patient floors for chart reviews.
-Requires corrected vision and hearing to normal range.
-Requires working under stressful conditions.
-Excellent interpersonal skills in dealing with co-workers, physicians and their office staff, other Work Areas, and the public.
-Must have strong initiative, excellent judgment, good problem solving skills, and excellent interpersonal skills.
-Develop and maintain positive working relationships among all levels of the organization in order to effectively develop and implement key initiatives.
Please note that all new hires with Grand Lake Health System must pass applicable pre-employment testing prior to working here. Beginning in 2013, nicotine screening has been added to our pre-employment screening. A positive nicotine test will result in non-approval to work at GLHS. Click OK to continue.Ok Cancel