Clinical Documentation Improvement Specialist
Location: METROHEALTH MEDICAL CENTER
Biweekly Hours: 80.00
Shift: Monday-Friday; Days
Summary:
Responsible to ensure all conditions and treatments are accurately, completely, and compliantly documented in the medical record for proper MS DRG and APR DRG assignment, capture of severity‑of‑illness (SOI) and risk‑of‑mortality (ROM) levels and to reflect the quality of care provided based upon CMS rules and regulations. Works collaboratively with MHS Medical Staff, HIM Coders, quality improvement professionals and other members of the healthcare team to achieve optimal outcomes. Keeps abreast of industry changes impacting role. Educates members of the patient care team both formally and informally regarding clinical documentation guidelines and service specific requirements. Upholds the mission, vision, values, and customer services standards of The MetroHealth System.
Qualifications
Required: Possesses one of the following:
RN - Registered Nurse licensure (BSN required if hired after April 2023).
RHIA – Registered Health Information Administrator.
RHIT – Registered Health Information Technician (Bachelor’s degree required), five years of experience in an inpatient acute care environment as a clinician or hospital inpatient coder. Demonstrated knowledge and proficiency in using clinical information systems and office automation, strong understanding of pathophysiology and disease management, broad‑based clinical background, excellent verbal and written communication skills, critical thinking skills, ability to work effectively with medical providers, handle multiple tasks and educational activities, work independently, self‑directed, travel to various clinical areas as assigned, and interact effectively with a wide range of cultural, ethnic, racial, and socioeconomic backgrounds.
Preferred: Active CCDS (Certified Clinical Documentation Specialist) from ACDIS or active CDIP (Certified Documentation Improvement Practitioner) from AHIMA; graduate degree in a related field; one to three years inpatient clinical documentation improvement experience in a tertiary academic healthcare system; working knowledge of Medicare reimbursement and ICD‑10 coding structures; demonstrated knowledge of the EPIC electronic medical record and 3M 360 Encompass systems; use of Microsoft Office software such as Word, Excel, and PowerPoint.
Physical Demands: May need to move around intermittently during the day, including sitting, standing, stooping, bending, and ambulating; may need to remain still for extended periods, including sitting and standing; ability to communicate in face‐to‑face, phone, email, and other communications; ability to read job‑related documents; ability to use computer.