Clinical Documentation Improvement

To be part of our organization, every employee should understand and share in the YNHHS Vision, support our Mission, and live our Values. These values - integrity, patient-centered, respect, accountability, and compassion - must guide what we do, as individuals and professionals, every day.

The Clinical Documentation Specialist I (RN), while incorporating the skills of the Clinical Documentation Associate, is expected to demonstrate a higher level of comprehension and expertise in Clinical Documentation Improvement and Coding knowledge. A CDI Specialist I will facilitate modifications to clinical documentation, through extensive real time interactions with physicians and other clinicians to reflect appropriate clinical severity, complications and co-morbidity. The specialist shall concurrently review and evaluate selected patient 's medical records for overall quality and completeness. Collaborate with Clinicians, nurses and coding staff on an ongoing basis regarding documentation opportunities, coding and reimbursement issues and relevant quality and performance improvement opportunities. Will identify quality of care issues in documentation and will seek resolution of issue through appropriate channels.

EEO/AA/Disability/Veteran

• Reviews medical records of hospitalized patients to identify the most appropriate principal diagnosis, secondary diagnoses, procedures, and assign a working DRG. Performs initial reviews, concurrent reviews and retrospective reviews to ensure the DRG accurately reflects the principal diagnosis and all comorbid conditions after study.
• Independently evaluates record for missing diagnoses pre and post discharge.
• Completes reviews to ensure working DRG and all comorbid conditions are documented by the providers to the greatest specificity.
• Collaborate with the coding staff concurrently and retrospectively to ensure the chart has all the necessary documentation to support the most accurate coding.
• Educates CDS staff on clinical documentation and coding guidelines. Develops and conducts ongoing Clinical Documentation Management program (CDMP) education for new staff including new clinical documentation specialists, coders, physicians, residents, nursing and allied health professionals.
• Develops and supports strong professional relationships with CDS, Coding staff, Physician leadership and Clinicians across the system.
• Utilizes a compliant query process per guidelines and policy when sending all queries. Follows each query through to closure including complete documentation of ongoing follow up activities and communication
• Works collaboratively with all licensed independent providers to ensure positive program outcomes
• Provides CDI training to providers one on one, during staff meetings or department meetings
• Assists in other monitoring activities, special department projects or other needs as determined by the department management
• Provides ongoing CDS team learning opportunities by sharing professional knowledge
• Orients new hires to YNHHS CDI program
• Provides feedback on current process and coding knowledge
• Maintains integrity and compliance in all chart reviews, CDI documentation and queries at all times
• Follows a process designed to allow effective risk adjustment and reimbursement
• Maintains an audit score > 95%
• Supports and implements quality measures as identified by department management
• Identify and implement opportunities for performance improvement

EDUCATION

• Registered Nurse with active RN license required. BSN preferred. Certified Clinical Documentation Specialist (CCDS) through ACDIS or Certified Documentation Integrity Specialist Practitioner (CDIP) though AHIMA and/or Certified Coding Specialist (CCS) through AHIMA preferred. Minimum of one (1) year of recent CDI experience meets requirement of Clinical Documentation Associate and submits completed CDI I Leadership Portfolio.

EXPERIENCE

• Clinical expertise required. CDI experience for a minimum of one (1) year is required.

LICENSURE

• RN license required. CCDS, CCS preferred.

SKILLS SPECIAL

• Excellent communication, negotiation and organizational skills.
• Adaptability to a wide variety of interpersonal encounters with the entire hospital team.
• Comprehensive understanding in use of medical records to extract data.
• Willingness to learn clinical and coding concepts.
• Exhibits working knowledge of third party and prospective payment systems.
• Computer literacy required.
• Ability to work on various software platforms.
• Must be capable of working collaboratively and independently.
• Must display flexibility with responsibilities to meet departmental needs.
• Must have keen eye to detail.

PHYSICAL DEMAND

• Ability to communicate clearly and confidently with providers regarding the program's goals and documentation issues using email, in person communication, telephone and other written and electronic forms of communication.