Clinical Documentation Improvement Specialist
This is a work on site position located in Scranton, Pennsylvania. The Clinical Documentation Improvement Program (CDI) is designed to improve the physician's documentation in the patient's medical record, supporting the appropriate severity of illness, expected risk of mortality and complexity of care of the patient. The role of the Clinical Documentation Improvement Specialist (CDIS) is to assist the providers with accurately identifying and documenting the healthcare services provided to the patient. This is accomplished with the recognition of complete and accurate diagnoses, procedures performed, and the treatment provided. The core of the program uses highly trained staff members to perform a concurrent inpatient review of the record. This allows the record to be coded post discharge in a timely and accurate manner. A highly successful CDI program is based on a highly interactive process between physicians, CDIS staff and other support services. The program does not challenge the provider's medical judgement, but rather provides a methodology in which to clarify existing documentation.
The role is full-time, 40 hours weekly, Monday through Friday. A minimum of 3 years RN work experience is required. BSN is strongly preferred.
Job duties include:
- Reviews inpatient medical records within 24-48 hours of admission for a specified patient population to evaluate documentation to assign the principal diagnosis, relevant secondary diagnoses, and procedures for accurate DRG assignment, risk of mortality, severity of illness; and initiate documentation of the review.
- Pursues a subsequent review of records every 3 days to support and assign a working DRG assignment upon discharge.
- Formulates queries when it is determined there is missing documentation, conflicting documentation or unclear documentation.
- Provides on-going education to physicians and essential healthcare providers regarding clinical documentation improvement and the need for accurate and complete documentation in the patient's record.
- Collaborates with nursing staff, nutrition, pharmacist, along with the physicians on documentation and to resolve queries prior to the patient's discharge.
- Consistently meets established productivity targets for record review.
- Identifies strategies for sustained work process changes that facilitate complete, accurate clinical documentation.
- Participates in the analysis and trending of statistical data for specified patient population; identifies opportunity for improvement.
- Promotes a partnership with the inpatient coding professionals to ensure the accuracy of principal diagnosis, procedures and completeness of supporting documentation to determine the working and final DRG, severity of illness and risk of mortality.
- Acts as a resource person for the interdisciplinary team in order to promote collaboration and coordination of patient care considering age specific, developmental, cultural, and spiritual needs of the patient.