The Clinical Documentation Integrity Specialist II(CDI) is responsible for
utilizing independent clinical judgement in facilitating the integrity, overall
quality, accuracy, and completeness of provider-based clinical documentation in
the medical record. This position is responsible for collaborating with
healthcare providers to ensure the documentation in the medical record
accurately reflects the severity of illness and risk of mortality of the
patient. The CDI Specialist assesses the clinical documentation through
extensive reviews of the medical record, interaction with all members of the
healthcare team and the Healthcare Information Management (HIM) Coding team to
ensure appropriate coding and Diagnosis Related Group (DRG) assignment for the
level of services rendered to the patient and to ensure that the clinical
information utilized in profiling and reporting outcomes is complete and
accurate.
RESPONSIBILITIES
Ensures hospital case-mix index and severity profiles are accurate by performing
timely medical record review, determination of working Diagnosis Related Group
(DRG) assignment and applying clinical expertise to identify opportunities for
improved or clarified documentation that accurately reflects the severity of
illness (SOI) and risk of mortality (ROM) of the patient. Direct and timely
follow-up with clinical providers to ensure requested clarification is
provided.
Responsible and accountable for expanding own nursing and Clinical Documentation
Integrity (CDI) knowledge (keeping up to date on latest research, technology,
treatment modalities, etc.)
Responsible and accountable for reading annual American Health Information
Management Association (AHIMA) coding guidelines, updates and understanding of
coding clinics.
Responsible and accountable for annual reading of the American Health
Information Management Association (AHIMA) Guidelines for Achieving a Compliant
Query Practice.
Utilizes critical thinking/problem solving processes.
Appropriately utilizes and interprets professional association resource
materials and regulatory agencies guidelines to enhance own skill sets: Coding
Clinics, American Health Information Management Association (AHIMA), Association
of Clinical Documentation Integrity Specialists (ACDIS), Centers for Medicare
and Medicaid Services (CMS) guidelines.
Identifies concurrent and retrospective query opportunities for medical record
integrity.
Working knowledge of compliant query writing so that the question is easily
understood by the clinician.
Escalates non-response to query by clinicians immediately according to query
escalation policy.
Collaborates with the coding, clinical documentation integrity team and clinical
staff.
Demonstrates proficiency in establishing and reconciling Diagnosis Related Group
(DRG) processes compliant with departmental guidelines and Centers for Medicare
and Medicaid Services (CMS) regulations.
Accurately reconciles all cases in Clinical Documentation Integrity (CDI)
database >90% of the time; determined by quality audit
Maintain current clinical documentation integrity specialist production
standards as outlined in Centra Health’s Health Information Management policy.
Demonstrates good working and background knowledge in reviewing increasingly
complex severity of illness (SOI) and risk of mortality (ROM) cases.
Demonstrates proficiency and efficiency in covering all units, specialties, and
hospitals
Other Functions:
Applies knowledge of health care workflows to work collaboratively with medical
staff and other health care team members to improve the overall accuracy and
comprehensiveness of medical record documentation, with focus on accurate
reporting of quality outcomes.
Good working knowledge of Hospital Acquired Condition (HAC)/Patient Safety
Indicator (PSI) query opportunity utilizing resources and follows department
guidelines for Hospital Acquired Condition (HAC)/Patient Safety Indicator (PSI)
query processes.
Good working knowledge on the impact of accurate clinical documentation in the
medical record to establish a working Diagnosis Related Group (DRG): accurate
billing, public reporting, research data, quality metrics, provider scorecards,
accuracy of the Uniform Hospital Discharge Data Set (UHDDS), Case Mix Index
(CMI).
Seeks and provides feedback for improving Clinical Documentation Integrity (CDI)
practice and integrity/quality of medical record documentation.
Good working knowledge involving high efficiency and accuracy to identify and
reduce Diagnosis Related Group (DRG) downgrades/denial risks by assuring that
clinical support is valid for DRG integrity, coding, and billing needs.
Meets established operational and productivity standards.
Consistently meets productivity, quality, and American Health Information
Management Association (AHIMA) and Association of Clinical Documentation
Integrity Specialists (ACDIS) ethical standards.
Proficient and efficient use of the Clinical Documentation Integrity (CDI)
business platform [3M, PowerChart, Cerner]
Performs other duties as assigned.
Ability to perform duties Monday through Friday, 40-hour work week
Maintain Centra Health policies and procedures, including vaccinations, etc.
Working towards gaining an advanced nursing degree or Certified Clinical
Documentation Integrity Specialist (CCDS)
Must maintain registered nurse licensure.
QUALIFICATIONS
Required Certifications and Licensures: Registered Nurse in the State of
Virginia or compact state. CCDS, CDIP eligible.
Required Experience / Skills: 2 years Clinical Documentation Integrity
Specialist experience. Has met/exceeded Clinical Documentation Integrity
Specialist I skills. Completes CDI competency assessment with 95% accuracy.
Must have thorough clinical skills (i.e. current working knowledge of
pathology, pharmacology, surgical procedures, etc.). Excellent written and
verbal communication skills. Ability to function independently and as a team
player in a fast-paced environment. Detail-oriented, and relationship building
skills. Demonstrates and has extensive knowledge of disease pathophysiology.
Demonstrated ability to use PCs, Microsoft Office suite, and general office
equipment (i.e., printers, copy machine, FAX machine, etc.).
Salary: $36.67- $53.17