Clinical Documentation Improvement Spec. I

Clinical Documentation Improvement Specialist I

BJC HealthCare is seeking an experienced critical care nurse to join our team as a Clinical Documentation Improvement Specialist I! Barnes-Jewish Hospital at Washington University Medical Center is the largest hospital in Missouri and is ranked as one of the nation's top hospitals by U.S. News & World Report.

The Clinical Documentation Improvement Specialist I uses clinical and coding knowledge for conducting clinically based concurrent and retrospective reviews of both inpatient and outpatient medical records reviews to evaluate the clinical documentation of clinical services by identifying opportunities for improving the quality of medical record documentation. This position facilitates and obtains appropriate physician documentation for any clinical conditions or procedures to support the appropriate severity of illness, expected risk of mortality, and complexity of care of the patient.

Responsibilities include:

• Reviews clinical documentation to facilitate the accurate representation of the severity of illness, expected risk of mortality, and complexity of care by improving the quality of the physician's clinical documentation.
• Utilizes hospital coding code set, policies and procedures, federal and state coding reimbursement guidelines, and application of the Coding Clinic Guidelines to assign working diagnosis-related groups (DRG); review patient records throughout hospitalization that have been identified as focus DRG by regulatory agencies or the facility to ensure the codes are reported at the highest specificity.
• Initiates physician interaction when abnormal ancillary test findings, ambiguous, missing or conflicting information is in the medical record, through the physician query process and/or participation in rounding with the physicians by requesting additional documentation for correct coding and compliance necessary for accurate reflection of CMI, LOS, and optimal resource utilization.
• Partners with other healthcare disciplines and HIMS coding staff to ensure accuracy of diagnostic and procedural data and completeness of supporting documentation to reconcile the working and final DRG, severity of illness, risk of mortality and quality outcomes.
• Initiates medical record review within 24 to 48 hours of admission; systematically monitors the targeted medical records within at least 48 hours (unless otherwise indicated) to determine compliance to established documentation standards; conducts follow-up reviews to ensure points of clarification have been addressed/documented in the medical record.
• BJC has determined this is a safety-sensitive position. The ability to work in a constant state of alertness and in a safe manner is an essential function of this job.

Minimum Requirements:

Education: Nursing Diploma/Associate's - Nursing

Experience: 2-5 years

Licenses & Certifications: RN

Preferred Requirements:

Education: Bachelor's Degree - Nursing

Experience: 5-10 years

Supervisor Experience: No Experience

BJC Total Rewards At BJC we're committed to providing you and your family with benefits and resources to help you manage your physical, emotional, social and financial well-being.

Comprehensive medical, dental, vison, life insurance, and legal services available first day of the month after hire date Disability insurance* paid for by BJC Annual 4% BJC Automatic Retirement Contribution 401(k) plan with BJC match Tuition Assistance available on first day BJC Institute for Learning and Development Health Care and Dependent Care Flexible Spending Accounts Paid Time Off benefit combines vacation, sick days, holidays and personal time Adoption assistance