Clinical Documentation Integrity Specialist

Nuvance Health has a network of convenient hospital and outpatient locations — Danbury Hospital, New Milford Hospital, Norwalk Hospital and Sharon Hospital in Connecticut, and Northern Dutchess Hospital, Putnam Hospital Center and Vassar Brothers Medical Center in New York — plus multiple primary and specialty care physician practices locations, including The Heart Center, a leading provider of cardiology care. Non-acute care is offered through various affiliates,
Summary:
Facilitates improvement in the overall quality, completeness and accuracy of medical record documentation. Obtains and promotes appropriate Clinical Documentation through extensive interaction with physicians, nursing staff, other patient caregivers, the Coding team and Health Information Management Department to ensure Clinical Documentation is complete and accurate and reflects severity of illness and resource utilization. Participates in the education of all members of patient care team on documentation guidelines, on an on-going basis.
Responsibilities:
1. Facilitates appropriate Clinical Documentation to ensure the level of services and acuity of care are accurately reflected in the medical record. Accurately performs admission reviews for specific patient populations using Clinical Documentation guidelines. Communicates with ancillary personnel (e.g., PT, RT etc) to clarify potential documentation opportunities. Extensively reviews all physician and Clinical Documentation, lab results, diagnostic information, treatment plans and captures appropriate information in 3M. Utilizes clinical skills to identify documentation opportunities that reflect severity of illness, acuity and resource consumption. Effectively communicates with appropriate physician(s) to ensure documentation opportunities are clarified. Utilizes AHIMA approved format to post physician queries 100% of the time.
2. Updates 3M to reflect any changes in patient status, procedures/treatments.Accurately updates 3M to reflect additional physician documentation, lab findings, diagnostic test results and treatment as appropriate. Effectively confers with physician to establish appropriate severity of illness and ensure documentation of principal diagnosis, comorbid conditions, complications and procedures. Meets the benchmark of 90% physician agreement rate and 90% physician response rate. Follows the process for unanswered queries.
3. Collaborates with coding staff as needed to determine appropriate DRG and required documentation. Provides clinical expertise and references to the coding staff as needed. Follows established guidelines for reconciling final coded DRG with the CDI DRG assigned at the time of discharge.
4. Remains current with and conducts on-going education regarding the Clinical Documentation Integrity program. Assists with the education of new staff, including new Clinical Documentation specialists, physicians, nursing and allied health professionals. Tracks and trends personal performance using 3M data. Attends and participates in educational conferences. Participates in concurrent performance improvement activities and on-going MR review activities. Reviews individual 3M data in conjunction with established benchmarks.
5. Maintains positive and open communications with physicians, interdisciplinary care team members, Department Head, Lead Clinical Documentation Specialist, coding management and coding staff.
6. Performs other related job duties as requested.
Other information:
1.MD, MBBS or Registered Nurse (RN) with 5 years recent experience (current NY/CT RN Licensure) in medical/surgical, critical care, intensive care or emergency room care preferred. Minimum BS preferred.
2. Professional Credentials
:
Licensure required for RN, CDIP, CCDS Certification preferred.
3. Must possess and consistently demonstrate strong interpersonal communication skills.
4. Ability to interact well with physicians and other members of allied health care team, including HIM and coders.
5. Must be computer literate or willing to learn how to use computer applications relative to the job.
Specific skills required:
Strong interpersonal and communication skills.
Ability to form positive, collaborative relationships with physicians and hospital staff.
Analytical abilities to assist in obtaining solutions to problems.
Work independently and prioritize work.
Able to manage multiple priorities.
Location: Danbury-24 Hospital Ave
Work Type: Full-Time
Standard Hours: 40.00
FTE: 4.000000
Work Schedule: Day 8
Work Shift: Monday-Friday 7 am - 3pm
Org Unit: 1767
Department: Clincial Document Improvement
Exempt: Yes
Grade: S11
Salary Range:
$32.6400 - $65.0100 Hourly
Credentials:
Essential:

• Registered Nurse

Working conditions:
Essential:

• Some manual skills / motor coord & finger dexterity
• Some occupational risk
• Sedentary/light effort. May exert up to 10 lbs. force
• Some exposure to dirt, odors, noise, human waste, etc.

EOE, including disability/vets.
We will endeavor to make a reasonable accommodation to the known physical or mental limitations of a qualified applicant with a disability unless the accommodation would impose an undue hardship on the operation of our business. If you believe you require such assistance to complete this form or to participate in an interview, please contact Human Resources at 203-739-7330 (for reasonable accommodation requests only). Please provide all information requested to assure that you are considered for current or future opportunities.