Clinical Documentation Improvement Specialist
Shriners Hospitals for Children believes that its long-term success as the world’s finest philanthropic healthcare system depends on the dedication of each employee to a core set of values. These core values embrace the concept that all employees are valued members of the family-centered patient care team. The patient care team as a whole is comprised of two equally important interdependent units i.e., support service personnel and multidisciplinary direct patient care employees. It is essential that each team member perform in a manner that exemplifies the belief in our core values.
The Clinical Documentation Improvement (CDI) Specialist is responsible for facilitating improvement in the overall quality and completeness of provider clinical documentation, ensuring documentation for clinical conditions and procedures reflects the severity of illness, expected risk of mortality, complexity of care of the patient, and supports ICD-10 coding. The CDI Specialist must also exhibit knowledge of documentation requirements utilized in research, billing and reimbursement, quality, and outcomes reporting. The CDI Specialist educates members of the patient care team regarding documentation guidelines, including attending physicians, allied health practitioners, nurses, and care managers.
Completes initial reviews of patient records to evaluate documentation in order to identify and assign the principal diagnosis, pertinent secondary diagnoses, and procedures for accurate assignment of the working DRG, risk of mortality, and severity of illness. Completes follow up reviews. Analyzes clinical information. Formulates appropriate clinical documentation clarifications to improve documentation. Queries and educates physicians and key healthcare providers regarding clinical documentation improvement. Participates in education of members of the patient care team. Identifies opportunities in concurrent and retrospective inpatient clinical medical documentation to support quality, regulatory compliance, and effective coding, and facilitates comprehensive medical records which accurately reflect medical documentation, decision-making, and treatment. Requires strong understanding of the requirement for clinical coding and billing according to the rules of CMS and commercial health plans.
Working knowledge of Microsoft Office Suite, including Excel, Word, PowerPoint, and Outlook; prior experience using 3M 360 Encompass; excellent written, verbal and presentation skills; superior interpersonal skills; excellent business judgment, effective decision making, and business savvy; experience working collaboratively with IT, HIM, and Clinical Operations, strong understanding and appreciation for the automation of the revenue cycle functions and the engagement of the customer in that automated process; knowledge of applied statistics, process analysis, and outcomes analysis.
Graduate of an accredited school of nursing with a BSN or Health Information Management program with RHIT designation required.
Minimum of 5 years of clinical healthcare experience in an acute care hospital required.
Minimum of 2 years of acute care clinical documentation improvement experience required.
Functional knowledge and understanding of ICD-10-CM coding and DRGs required.
RHIA and CDI Certification preferred.
Five years acute Case Management, Utilization Management, Quality review, inpatient/outpatient coding, or other related clinical experience in an acute care pediatric facility preferred.
Registered Health Information Administrator
Registered Health Information Technician
Process Analysis (Business)