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Clinical Documentation Improvement Specialist -- Nurse preferred

Summary:

The Clinical Documentation Improvement professionals are exposed to robust institutional and physician support for quality documentation, access to an advanced electronic medical record system and state-of-the-art clinical documentation software. 

Through interaction with physicians, nursing staff, medical records coding staff/compliance specialists and other healthcare providers, clinical documentation analysts facilitate modifications to clinical documentation ensuring accurate depiction of the level of clinical services, reason for admission, patient severity, risk of mortality, severity of illness and conditions present on admission.

Duties:

  • This position is responsible for improving overall quality and completeness of medical records.
  • Review medical record documentation for quality and possess ability to convey deficiencies to house staff and attending physician for resolution.
  • Compile and document chart findings in dedicated database on a daily basis.
  • Communicate with and educate members of the patient care team (physicians and advanced practice providers) and others on the clinical documentation concepts on an ongoing basis.
  • Participation on select committees and providing educational programs as necessary.
  • This position may also be responsible for reviewing overall quality and completeness of coding by reconciling differences in the MS-DRG assignment through comparison and analysis of the coding summary and CDI patient summary against medical record documentation.
  • Utilize current coding guidelines, conventions and AHA coding clinics to accurately determine the principal and secondary diagnoses and procedures that affect the MS-DRG assignment.
  • Communicate with coders, compliance specialists and/or clinical documentation analysts regarding documentation clarification and accurate coding.

Education and Experience:

  • One of the following is required;
    • BSN
    • PA (Physician's Assistant)
    • NP (Nurse Practitioner)
    • Doctorate degree in a medically related field.
  • 3+ years of relevant experience and appropriate certifications. For Nurses; case management or utilization review and acute care clinical experience is preferred.
  • Must have current licensure as an RN, NP, PA or licensure in the specific medical field associated with a Doctorate degree.

 

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