Primary Purpose
The Clinical Documentation Integrity Specialist (CDIS) performs patient record reviews to establish complete, accurate and timely documentation of all conditions that support hospitalization and treatment of the patient. Present queries to the medical staff when needed to clarify ambiguous or incomplete documentation. Must have knowledge of ICD-10, Complications/Comorbid Conditions and their role in the final Diagnosis Related Group, Severity of Illness and Risk of Mortality.
Minimum Specifications
Education
Must have one of the following:•
Degree in nursing from an accredited college or university.
A medical degree (MD, DO)
Master’s Degree in a Healthcare/Medical related field from an U.S. accredited college or university
Graduated from an accredited Health Information Management (HIM) program.
Experience
For MD or DO:
Must have two (2) years of clinical experience
For RNs:
Three plus (3+) years of clinical experience in an acute care setting (ICU/Critical Care / Surgery Specialty)
For HIM Professionals:
Must have two plus (2+) years of experience working with the coding classification systems, medical terminology, anatomy and physiology and disease processes. Two (2) years of inpatient coding experience
Equivalent Education and/or Experience
May have an equivalent combination of education and experience in lieu of specified educational and experience requirements.
Certification/Registration/Licensure
Because of the lag in SCCE, HCCA, NCRA, and AHIMA updating the status of certifications, current employees whose certification is granted through one of these associations are allowed up to seven (7) calendar days, after expiration, to provide proof of renewal. Although an additional seven (7) calendar days is allowed to provide proof of renewal, there cannot be a lapse in the certification’s “active” status.•
For MDs Only:
Must have graduated from a medical school and obtained a Medical Degree
For RNs Only:
Must have current RN license or valid temporary permit with the Texas Board of Nursing; or, valid Compact RN license.
For HIM Professionals Only:
Must have current Certified Coding Specialists (CCS), or
Registered Health Information Technology (RHIT), or
Registered Health Information Management Administrator (RHIA).
Skills or Special Abilities
Organizational, analytical, writing and interpersonal skills.
Must be able to be comfortable teaching in group settings as a large part of the job is educating healthcare providers about current documentation standards and helping them appreciate their role in documentation improvement.
Must possess expert knowledge of medical terminology, anatomy & physiology and ICD-10 and CPT coding principles.
Must be able to communicate effectively with physicians, nursing and ancillary staff.
Must be able to demonstrate patient centered/patient valued behaviors.
Must demonstrate knowledge and skill in age specific needs and the elements of disease processes and related procedures.
Must be able to demonstrate a working knowledge of MS Office software, including Word, Excel, and PowerPoint.
For RN applicants:
RN applicants must maintain standards of professional conduct and performs all assigned and unassigned duties in accordance with the current State of Texas Nurse Practice Act.
RN Applicants must pass Medication Examination prior to hospital orientation. Current Parkland employees requesting reassignment to role must have current Medication Examination on file.
Responsibilities
Collaborates with physician, physician extender, nurse, case manager/utilization reviewer and HIM coder to identify principal diagnosis options, secondary diagnoses and procedures, to assign working MS-DRGs and or APR-DRG for at least 85% of identified populations.
Conducts initial and extended-stay concurrent reviews on all selected admissions and documents findings within 3M CDIS software.
Identifies need to clarify documentation in records and utilizes strong communication skills with physician, physician extender, nurse or other healthcare professionals, utilizing appropriate tools to capture needed documentation. Works collaboratively with the healthcare team to facilitate documentation within the medical record that supports patient's severity of illness and risk of mortality.
Serves as a resource to physicians and administration regarding issues to the appropriateness of inpatient MS-DRG and APR-DRG assignment.
Assists in the development of query response physician reports. Maintains complete confidentiality of patient information, in addition to hospital and individual physician practice pattern data.
Provides information and in-services as necessary to physician and ancillary staff.
Job Accountabilities
Identifies ways to improve work processes and improve customer satisfaction. Makes recommendations to supervisor, implements, and monitors results as appropriate in support of the overall goals of the department and Parkland.
Stays abreast of the latest developments, advancements, and trends in the field by attending seminars/workshops, reading professional journals, actively participating in professional organizations, and/or maintaining certification or licensure. Integrates knowledge gained into current work practices.
Maintains knowledge of applicable rules, regulations, policies, laws and guidelines that impact the area. Develops effective internal controls designed to promote adherence with applicable laws, accreditation agency requirements, and federal, state, and private health plans. Seeks advice and guidance as needed to ensure proper understanding.
Must have relevant clinical or HIM degree and clinical or coding experience (2–3+ years depending on background). Requires RN license for RNs or applicable HIM credentials (CCS, RHIT, RHIA). Strong knowledge of ICD-10, CPT, medical terminology, and MS-DRG/APR-DRG.
Key Responsibilities
- reviewing records
- identifying diagnoses
- educating providers
Skills & Tools
3M CDIS, Microsoft Word, Microsoft Excel, Microsoft PowerPoint, ICD-10, CPT
Job Details
- Category: Healthcare Services - Allied Health
- Seniority: Mid Level
- Commitment: Full Time
- Workplace: Remote — Texas, United States
- Languages: English
About Parklandhospital
A large public hospital system focused on delivering exceptional, patient-centered care to the Dallas community. — Industry: Healthcare