Clinical Documentation Improvement Specialist - Clinical Doc Integrity - FT Days

QUALIFICATIONS

The ideal candidate will possess a strong clinical background, with a minimum of five years of recent hospital experience as a Registered Nurse (RN), four years of recent clinical experience for Nurse Practitioners (NP), or Physician Assistants (PA). They should demonstrate strong organizational and analytical skills and be dependable, with a proven ability to manage their time and responsibilities independently and efficiently with minimal supervision. Professionalism in appearance and conduct is essential. The candidate must be capable of handling multiple priorities while consistently meeting productivity targets. Proficiency in computer use, including familiarity with electronic health records and Windows-based software programs such as Microsoft Office, is required. Additionally, the candidate must be willing and able to understand and support Clinical Documentation Management Program (CDMP) documentation strategies upon completion of relevant training.

Required: Current Oregon RN, NP, LPN, or PA license

TYPICAL PHYSICAL/MENTAL DEMANDS

Light physical demands include sitting/standing at computer terminal for an extended period of time. Mental demands include critical thinking, problem solving and deductive reasoning skills; and the ability to make decisions in stressful situations.

ESSENTIAL JOB FUNCTIONS

• Identifies records for review based on prioritization by length of stay, diagnosis, and other defined CDI strategies.
• Reviews records and accurately identifies opportunities for improvement in physician documentation related to appropriate assignment of MS-DRG, and capturing major co-morbidities/complications (MCCs) and co-morbidities/complications (CC’s), as appropriate to the payer system.
• Identifies opportunities for increasing specificity and accuracy of documentation.
• Formulates clinically credible documentation clarifications
• Effectively communicates with physicians to obtain clarifications in a timely and compliant manner.
• Follows up as needed to ensure a high rate of query responses.
• Monitors the CDI process and personal effectiveness to ensure CDS activities are on track to meet the goals of the program.
• Consults with Inpatient CDI Manager as needed to optimize process related to specific high-volume high-risk diagnoses.
• Communicates with HIM staff and resolves discrepancies in a collaborative manner.
• Participates in identification of opportunities for CDI intervention via query or physician education.
• Helps ensure the confidentiality and security of patient information accessed through his/her department.

MARGINAL JOB FUNCTIONS:

· Performs other duties as assigned.