• Clinical Documentation Integrity Specialist

    Job ID
    2020-27646
    Employment Type
    Full Time
    Hours Per Week
    40
    Address
    200 S.E. Hospital Ave
    City
    Stuart
    State
    FL
  • Overview

    The Clinical Documentation Improvement Specialist (CDIS) is responsible for facilitating the improvement in the overall quality and completeness of medical record documentation. Obtains appropriate clinical documentation through extensive interaction with physicians, nursing staff, other patient caregivers, and Health Information Management 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.

    Responsibilities

    • Utilize extensive knowledge of documentation requirements and guidelines in accordance with the Coding Clinic to improve the overall quality and completeness of clinical documentation by performing concurrent stay reviews.
    • Utilize nThrive technology to track documentation notes and observations, assign Working DRG and calculate Query DRG to reflect the impact of queries initiated, complete query entry for tracking purposes and complete validation process to ensure diagnosis located in EMR or attained by a query are finally coded.
    • Educate internal staff on clinical documentation needs, changes to clinical documentation guidelines, coding and reimbursement issues, and conduct follow up reviews of clinical documentation to ensure points clarified with the physician have been recorded in the patient’s record. 
    • Follow established workflows and processes developed for Clinical Documentation Improvement, Strategic Source.
    • Compose and initiate AHIMA compliant queries.
    • Utilize Nthrive CDI technology and follow established standardized process flow.
    • Maintain open communication with coding to discuss DRG assignment, diagnosis, clinical indicators, coding clinics and guidelines and educating each other on the specialty.
    • Assign Working DRG for Case Management department to view the Length of Stay (LOS) of patients.
    • Pass annual analysis and evaluation.
    • Participate and provide input regarding CDI program activities, and attendance at routine team meetings.
    • Maintain current skill set with regard to government regulations, compliance and reimbursement guidelines.
    • Expected to keep abreast of new legislation and regulations that affect CDI.
    • Maintain personal and professional education and growth. 
    • Responsible for maintaining continuing education credits as required by credentialing organization.

    Qualifications

    • Licensed as a Registered Nurse with an Associate Degree (ADN) or Bachelor’s degree in Nursing (BSN), or an MD
    • 3+ years of recent acute care nursing experience required.
    • Clinical expertise required.
    • Computer PC literacy required.
    • Must be an excellent communicator, negotiator and have great organizational skills.
    • Strong knowledge of clinical documentation guidelines required. 
    • Must be able to work collaboratively and independently.
    • Must be flexible with responsibilities in order to meet departmental needs.
    • Must be able to demonstrate initiative and the ability to work in a fast-paced environment with proficiency in multi-tasking and prioritization.
    • Experience in computerized hospital/health information management systems and software applications are required. 

    Preferred Skills

    • Bachelor’s degree in Nursing (BSN) or MD preferred.
    • Certification in clinical documentation improvement (CCDS, CDIP) strongly desired.
    • Certified in coding (CCS) preferred.
    • Technical knowledge of ICD-10, DRG and APR assignment and prospective payment methodologies preferred.
    • Ability to write reports independent of management review is a plus.
    • Experience and/or knowledge of regulatory compliance issues facing the healthcare industry is also a plus.
    • Demonstrated customer-oriented management style.
    • Focused on team and collaboration. 
    • Ability to address critical issues and demonstrate self-initiation. 
    • Ability to think critically and analytically, anticipate challenges and trends.
    • Computer knowledge of MS Office, including Word, Excel, and PowerPoint is preferred. 
    • Working knowledge of automated system designs is preferred.

    About nThrive

     

    Be Inspired. Ignite Change. Transform Health Care. 

    From Patient-to-PaymentSM, nThrive provides all the technology, advisory expertise, services, analytics and education programs health care organizations need to thrive in the communities they serve. Our colleagues share a united passion to help health care organizations strengthen their financial position, which translates to accessible, quality care for all. This passion fuels our drive to innovate and participate in community outreach through the nThrive CARES program. Our colleagues are encouraged to think differently and empowered to make a lasting impact that ensures our health care providers, and our world, are healthy and productive.

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