Clinical Documentation Specialist
The Clinical Documentation Integrity Specialist (CDIS) provides clinically based, concurrent and retrospective reviews of all inpatient medical records. CDI strives to ensure accurate, complete, compliant, concise and consistent documentation that reflects the true clinical scenario of the patient’s encounter. This additionally serves to reflect the true Severity of Illness (SOI), Risk of Mortality (ROM), and Intensity of Services (IOS) rendered to provide quality care and treatment to the patient. The Clinical Documentation Integrity Specialist serves as a liaison between leadership, medical staff, nursing, coding, case management and quality departments. Excellent communication skills and the ability to critically analyze are essential to a successful CDI program. The CDIS I is an entry level position for new CDI Specialists in training.
- Provides clinically based, concurrent and retrospective reviews of all inpatient medical records. Ensures documentation accurately reflects quality of care, severity of illness and risk of morality to support correct coding, reimbursement and quality initiatives.
- Proactively contacts physicians or other clinicians as needed to clarify procedures/diagnoses to ensure proper documentation. This includes providing information to physicians and other clinical staff in educational sessions and “rounds” on the nursing units.
- Performs initial case reviews and follow up reviews as indicated by Iodine.
- Sends queries to providers as needed to ensure complete documentation of relevant diagnoses
- Assigns diagnosis codes following the Official Guidelines for Coding and Reporting and AHA Coding Clinics to obtain an accurate working DRG.
- Promotes a partnership with Coding/HIM team to ensure the accuracy of principal diagnosis, procedures, and completeness of documentation to determine the working and final DRG, severity of illness and risk of mortality. Functions as a liaison between clinical and coding teams.
- Actively engages and participates in delivery of education to physicians through extensive interaction one on one and in monthly medical staff meetings as needed.
- Promotes collaboration and engagement with physicians to support query education.
- Utilizes critical thinking skills and clinical reasoning to identify, clarify, and query accurate representation of documentation to reflect appropriate clinical status of the patient which will translate into quality reporting, physician report cards, reimbursement, public health data, and disease tracking and trending.
- Maintains professional competency in documentation and coding practices by keeping up to date on new coding guidelines, policies/procedures, federal and state reimbursement.
- Communicates effectively on a daily basis with the multidisciplinary team consisting of physicians, nurses, coders, administration and others.
- All tasks must be performed in accordance with the established Steward CDI daily workflow with adherence to Inpatient CDI Handbook protocols
- Communicates in a timely manner with CDI Manager, reporting potential and/or actual problems identified during the review process.
- Follows Steward query escalation process to address query response results that are untimely, missing, or inappropriate.
- Meets CDI Performance standards of ≥ 20 reviews per 8 hours worked, ≥ 30% query rate, ≤ 95% missed query opportunity, and reconciles all cases with ≥ 95% accuracy and in a timely manner
- Must possess strong organizational, communication and clinical foundation skills
- Must demonstrate proficiency in EMR software, CDI applications (after education and orientation) and Microsoft applications.
- Demonstrates ability to multi-task and work efficiently and effectively between software platforms
- Demonstrates the ability to communicate effectively in a fast-paced environment with multidisciplinary teams consisting of physicians, nurses, coders, administration and other health care professionals.
- Demonstrates proficiency in CDI process after completion of onboarding and orientation/education. Continued improvement in proficiency and accuracy is expected during and after orientation/onboarding.
- Experienced CDI Specialists are expected to onboard more quickly and meet performance metrics commensurate with their experience level.
- Proven ability to maintain confidentiality and HIPAA compliance at all times.
Education: Bachelor’s degree in a clinical or coding study is preferred.
Experience: 2- 5 years acute clinical or coding (IP) experience preferred. Clinical Documentation Integrity experience preferred
Certification/Licensure: RN or LVN with current State License, Proof of Certification when applicable
Software/Hardware: Proficiency in Microsoft applications, EMR applications, CDI and coding software