Clinical Documentation Improvement Specialist (CDIS)

SDV INTERNATIONAL is seeking highly motivated and highly skilled individuals who are ready for exciting opportunities with our growing company. For a decade, we've built our reputation as a premier health care solutions provider. We support Department of Defense military treatment facilities ("MTF"), and they need our help to improve their clinical environment. Do you have the following capabilities?

Position Description:

Our CDIS will:

• perform initial and follow-up assessments regarding the inpatient provider’s documentation skills. With each assessment, inpatient record reviews shall include verification of patient identification and demographics; reason for admission; disposition date; assignment of diagnoses; procedures documentation and health care provider’s signature.
• identify opportunities for improvement to ensure documentation used for measuring and reporting physician and hospital outcomes is accurate and complete.
• perform a baseline review of all inpatient health care providers to determine if CDIS are impacting documentation. The sample size for the review shall be between 2-5% per health care provider. The review shall start within 30 calendar days of contract startup and the results of the review shall be provided in a report to the Task Order Government POC per the following schedule:

Number of Providers Report Due After Start of Review Up to 350 Within 5 business days Between 350 and 700 Within 10 business days Greater than 700 Within 15 business days.

Our CDIS will:

• perform a baseline review of all new health care providers within 30 days of seeing patients to determine the current level of documentation detail. The sample size for the review shall be 2% per provider. A report of findings shall be provided to the Task Order Government POC within 5 business days of starting the review.
• concurrently review all medical records identified in the task order(s) to identify documentation deficiencies. For an inpatient stay, the CDIS shall review the provider documentation daily and recommend an addendum to the record if necessary. If the CDIS determines a provider’s documentation is not improving, the CDIS shall recommend to the Task Order Government POC a corrective action plan to identify specific areas of improvement, a remediation plan that includes a timeline in which to achieve positive results and a follow-up plan. The corrective action plan shall be approved by the Task Order Government POC prior to implementation. A summary of all providers placed on a corrective action shall be included in the monthly report of services rendered.
• perform focused inpatient medical record reviews. The initial review is performed within 24-48 hours of patient admission.
• communicate with physicians, case managers, coders and other health care team members to obtain comprehensive medical record documentation to support the severity of illness, expected risk of mortality, and complexity of care provided to the patient. Documentation obtained shall include clinical treatment and procedures, medical decisions and diagnoses for inpatients.
• initiate a query to the health care provider to clarify and explain any documentation that does not clearly and consistently describe the patient’s medical condition and hospital stay to assign the correct MS-DRG. Clarification includes obtaining accurate and complete documentation based on current clinical findings, prescribed treatment, medical interventions and/or
• conduct routine (non-query) follow-up reviews of the medical record every 3 days until the issue is resolved.
• review outstanding queries daily for provider responses and follow-up as needed to facilitate timely and accurate documentation.
• provide education to physicians and other members of the health care team regarding compliant documentation responsibilities, coding and reimbursement issues and documentation guidelines.
• investigate and analyze documentation issues/questions to generate and recommend solutions to the Task Order Government POC. The contractor shall prepare formal reports for the government with findings and recommendations regarding documentation, revenue and reimbursement issues. Formal reports shall be submitted to the Task Order Government POC by the 5th business day of each month.

Our CDIS will provide medical record documentation education to residents and interns in the MTFs Family Practice graduate medical education (GME) program.

• implement coding documentation improvement processes and disseminate new/updated information to improve documentation, RWP and Prospective Payment System (PPS) capture within five (5) business days after receiving approval from the government.
• educate the health care provider on the most efficient process for capturing data in the applicable system.
• evaluate Present on Admission (POA) indicators for each diagnosis that could potentially affect the principal diagnosis, quality indicators or MS-DRG assignment.
• validate data using government AIS’ and identify data capture trends, variations in coding practices and perform management analysis. The contractor shall use this data to provide feedback to taskers or queries from customers such as the MTFs or the Navy Medicine Region (East or West) in a variety of formats.
• monitor compliance with policies and procedures relevant to the clinical data management program, make recommendations to improve compliance, obtain government approval for implementation and take action.
• collect and analyze data to correct identified complex coding deficiencies and improve reimbursement capture.
• utilize enterprise-prescribed tools to monitor the completeness of clinical documentation and accuracy of code assignments.
• make daily rounds and interact with health care team members to ensure consistent documentation practices. The contractor shall work closely with any department impacting admissions to include, Scheduling, Insurance Verification, Operating Room (OR), Post-Anesthesia Care Unit (PACU), Emergency Department (ED) and the Admitting Office for direct admits. The contractor shall seek clarification from physicians regarding proper documentation as it relates to reimbursement.
• achieve minimum departmental productivity standards of 20-25 reviews per day, inclusive of initial and follow-up reviews.

Bachelor’s degree in a health-related field with a minimum of 5 years clinical experience including but not limited to; acute patient care, health services, public health, long-term care administration, hospital organization and management, strategic planning and health systems.

Two years in the last five years focused on inpatient coding, healthcare and coding regulations including code structure, clinical documentation, MS-DRG experience, criteria-based chart reviews (ex. Utilization Management or Case Management), and quality improvement experience working with a physician’s group.

**This job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required by this position.

** Qualifications: 5 Years’ experience with Bachelor’s Degree in Healthcare or affiliated specialty Required Skills: Medical Coding, ICD-10, Inpatient, DCPT, HIPAA compliance Required Certifications: AAPC CCP certified and one of the following AHIMA CDIP, RHIA, or RHIT. Must be a US Citizen ability to pass background investigation for Position of Trust

A coding assessment has to be taken and all credentials must be current and verification will be required.

Proof of immunizations is required.

Must be clearable; a government issued security clearance is required to start work.

EOE/V/D

VEVRRA Federal Contractor

Equal Opportunity Employer of protected veterans

SDV INTERNATIONAL has been serving clients in ever-changing environments by providing high quality coding, auditing, training and educational services to achieve and exceed the goals of our clients. Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, disability or protected veteran status.

Learn more about us at www.SDVinternational.com

We offer very competitive compensation for rock star specialists!

Do you have the right skills? If so, contact us today!

Job Type: Full-time