Documentation Specialist

The Clinical Documentation Improvement Specialist (CDS) facilitates the improvement in the overall quality and completeness of provider-based clinical documentation in the medical record. This position will be responsible for assisting treating providers to ensure that documentation in the medical record accurately reflects the severity of illness of the patient as well as the level of services rendered.  This involves extensive record review, interaction with physicians, advanced practitioners, health information management professionals, coding professionals, and nursing staff. Active participation in team meetings and training of staff in the Nuance CDI process is a key role.

This position will be 100% remote.

Major Role:

• Review inpatient medical records for identified payer populations on admission and throughout hospitalization.
• Analyze clinical information to identify areas within the chart for potential gaps in physician documentation.
• Formulate credible clinical documentation clarifications, following ACDIS/AHIMA guidelines, on a concurrent basis, to improve clinical documentation of principal diagnosis, co-morbidities, present on admission (POA), quality measures, and patient safety indicators (PSI).
• Communicate with physicians, advanced practitioners, case managers, coders and other members of the care team to facilitate comprehensive medical record documentation to reflect treatment, decision-making and medical documentation. 
• Assign a working MS/APR-DRG and severity level using coding rules and guidelines with follow up reviews as required by LOS standards. Working DRG should reflect the natural progression of the case.
• Conduct post discharge reviews for comparative analysis of CDI Specialist and HIM MS/APR-DRG and severity level assignment. Reviews clinical issues with the coding staff to assign a final DRG. Conducts Reconciliation on all cases with a change from working DRG or a mismatch.
• Communicate with physicians, nurse practitioners, case managers, coders and other members of the care team to facilitate comprehensive medical record documentation to reflect treatment, decision-making and medical documentation. 
• Participate in ongoing education of staff (physician, advanced practitioners, and ancillary staff).  Potential to assist in the development and presentation of educational materials and tools relative to documentation improvement practices for individual practitioners and groups of clinicians presented as handouts, PowerPoint, etc.

Skills Required

• Organizational, analytical, and writing skills
• Ability to demonstrate critical thinking, problem solving and excellent interpersonal skills
• Excellent time management
• Effective and appropriate communication with physicians, the clinical team & coding professionals
• Knowledge of regulatory guidelines
• Knowledge of Medicare Part A and MS-DRG and/or APR-DRG payment methodologies preferred
• Ability to pass a written clinical competency assessment
• Basic computer skills
• Knowledge of ICD10 coding, as well as strong computer skills (Microsoft Access, Excel, Word) preferred, however content training in coding will be provided.

Requirements: 

• Work requires the knowledge of theories, principles, and concepts typically acquired through completion of a Degree in Nursing, International Medical Graduate, Physician, Physician Assistant, Nurse Practitioner, or other Healthcare Provider
  • Will consider other Healthcare providers (Respiratory Therapist, Physical/Occupational Therapist, etc.), or HIM Professionals on a case-by-case basis
• Must possess Minimum 5 years of acute care hospital experience
• AHIMA CCA or CCS certification preferred
• ACDIS CCDS or AHIMA CDIP certification preferred
• Minimum 2 years of Inpatient Coding experience with ICD-10 CM/PCS preferred
• CDI experience preferred

Salary Range: $85,000 - $90,000