Clinical Documentation Improvement Specialist Join to apply for the Clinical Documentation Improvement Specialist role at St. Anthony Regional Hospital
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Promotes accurate, complete and timely clinical documentation by conducting regular evaluations of documentation in accordance with CDI policies and procedures.
Conducts real-time reviews of clinical documentation to ensure accuracy, completeness, and compliance with CDI policies and regulatory standards.
Participates in physician rounds and remains available throughout the day for real-time provider collaboration.
Issues queries in a professional and timely manner to clarify ambiguous, conflicting, or incomplete documentation.
Ensures documentation supports patient acuity, severity of illness, risk of mortality, case mix index, and appropriate reimbursement.
Maintains proficiency in CMS guidelines, third-party payer requirements, coding rules, and documentation standards.
Demonstrates understanding of clinical indicators, disease processes, complications, and co-morbidities.
Submits reports reflecting query activity, trends, and cost impact as required (e.g., monthly and quarterly).
Maintains a positive, respectful approach when interacting with physicians, nurses, HIM, coders, payers, patients, and families.
Adheres to Quality Management protocols for productivity and documentation integrity.
Promotes continuous improvement by identifying documentation-related issues and contributing to process enhancements.
Remains current on trends in CDI practices through continuing education and training.
Complies with all applicable federal, state, and organizational regulations and standards (e.g., HIPAA, CMS, JCAHO).
Follows safe work practices and maintains a clean, hazard-free work environment.
Maintains confidentiality of all patient, employee, and organizational information.
Performs other duties as assigned.
Job Details
Description
Essential Duties and Responsibilities
Promotes accurate, complete and timely clinical documentation by conducting regular evaluations of documentation in accordance with CDI policies and procedures.
Conducts real-time reviews of clinical documentation to ensure accuracy, completeness, and compliance with CDI policies and regulatory standards.
Participates in physician rounds and remains available throughout the day for real-time provider collaboration.
Issues queries in a professional and timely manner to clarify ambiguous, conflicting, or incomplete documentation.
Ensures documentation supports patient acuity, severity of illness, risk of mortality, case mix index, and appropriate reimbursement.
Maintains proficiency in CMS guidelines, third-party payer requirements, coding rules, and documentation standards.
Demonstrates understanding of clinical indicators, disease processes, complications, and co-morbidities.
Submits reports reflecting query activity, trends, and cost impact as required (e.g., monthly and quarterly).
Maintains a positive, respectful approach when interacting with physicians, nurses, HIM, coders, payers, patients, and families.
Adheres to Quality Management protocols for productivity and documentation integrity.
Promotes continuous improvement by identifying documentation-related issues and contributing to process enhancements.
Remains current on trends in CDI practices through continuing education and training.
Complies with all applicable federal, state, and organizational regulations and standards (e.g., HIPAA, CMS, JCAHO).
Follows safe work practices and maintains a clean, hazard-free work environment.
Maintains confidentiality of all patient, employee, and organizational information.
Performs other duties as assigned.
Supervisory Responsibilities
This job has no supervisory responsibilities.
Qualifications
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Education And/or Experience
Bachelor’s degree in healthcare administration, nursing, business, or related field required.
Minimum of 5 years of experience in clinical coding, case management, or direct patient care (critical care experience preferred).
Equivalent combination of education and experience may be considered.
Licensure/Certifications (Preferred But Not Required)
Certified Professional Coder (CPC)
Certified Professional Medical Auditor (CPMA)
Certified Coding Specialist (CCS)
Registered Nurse (RN) license
Skills And Competencies
Strong knowledge of coding guidelines, documentation standards, and healthcare reimbursement methodologies.
Effective communication, collaboration, and customer service skills.
Ability to independently manage workload and meet deadlines.
Proficient in electronic health records (EHRs) and documentation software systems.
Critical thinking and problem-solving abilities to identify and resolve documentation discrepancies.
Language Skills
Ability to read, understand, and follow written instructions, correspondence, and medical documents.
Ability to write simple correspondence clearly and accurately.
Ability to effectively present information in one-on-one and small group situations to patients, families, physicians, and coworkers.
Must demonstrate proficiency in speaking, reading, and writing in English.
Physical Demands
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Regularly required to stand, walk, talk, hear, use hands to handle or feel, and reach with arms.
May occasionally assist with patient transfers, positioning, or ambulation, requiring bending or stooping.
Infrequent kneeling or crouching may be required when retrieving supplies or equipment from low storage areas.
Must be able to lift and/or move up to 20 pounds frequently and up to 50 pounds occasionally.
Requires visual acuity for close and distant vision, color and depth perception, and ability to adjust focus.
Must be able to remain alert and responsive in a fast-paced clinical environment with potential exposure to bodily fluids and communicable diseases.
Work Environment
The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Primarily clinical setting with moderate noise levels.
May be exposed to bloodborne pathogens, chemicals, unpleasant odors, and patients in distress.
May occasionally be exposed to moving equipment, radiation, and combative patients.
Seniority level Seniority level Mid-Senior level
Employment type Employment type Full-time
Job function Job function Health Care Provider
Industries Hospitals and Health Care
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