Primary Function

The Clinical Documentation Improvement (CDI) Specialist (RN) is responsible for concurrently reviewing medical records to facilitate the accurate representation of the severity of illness by improving the quality of the physicians’ clinical documentation while maintaining compliance with HIPAA (Health Insurance Portability and Accountability Act of 1996) and Code of Conduct Policies.

• This involves extensive record review and interaction with physicians, coding professionals, nursing, and case management staffs at Kent Hospital, Memorial Hospital and Women and Infants Hospital.
• Communicate with physicians, case managers, coders, and other healthcare team members to facilitate comprehensive medical record documentation to reflect clinical treatment, decisions, and diagnoses for inpatients

Specifications

• Bachelor’s Degree in Nursing preferred with a minimum of five years acute care experience. Current Nursing license required.
• At least 2 years recent (ER, Critical Care, MED/SURG) inpatient experience required.
• Certified Clinical Documentation Specialist (CCDS/CDIP) preferred.
• Advanced clinical expertise and extensive knowledge of complex disease processes with broad clinical experience in the inpatient setting.
• Excellent oral and written skills and ability and knowledge to collaborate with clinical, operational and financial areas

Key Competencies

• Adaptability
• Creativity
• Critical thinking
• Dealing with ambiguity
• Innovation management
• Managing vision and purpose
• Planning
• Strategic agility

Application of Knowledge and Skill

• Demonstrates a comprehensive knowledge of all guidelines concerning the sequencing of diagnoses and procedures, including but not limited to, those outlined in ICD-10-CM, CPT, Uniform Hospital Discharge Data Set, Medicare guidelines and other appropriate classification systems.
• Ensures the accuracy and completeness of clinical information used for measuring and reporting physician and hospital outcomes.
• Utilizes the hospital’s designated clinical system to ensure compliant provider documentation.
• Provides or coordinates education to all internal customers related to compliance, coding and clinical documentation. Additionally acts as a liaison to coders when additional information or documentation is needed to assign the correct DRG.
• Develop formal and informal physician education strategies to promote complete and accurate clinical documentation and correct negative trends.
• Responsible for the day-to-day evaluation of documentation by the medical staff and healthcare team in accordance with the hospital’s designated clinical documentation system.
• Gather and analyze information pertinent to documentation findings and outcomes.
• Identify patterns, trends, variances and opportunities to improve documentation review process and performance improvement methodologies.
• Uses assertive interpersonal skills to discuss clinical documentation issues and work effectively with all levels of interdisciplinary team, such as physicians, coders, nursing and case manager.
• Develops compliant and effective verbal and written physician queries.
• Conduct follow-up reviews of clinical documentation to ensure points of clarification have been recorded in the patient’s chart.
• Participates in external DRG reviews such as RAC, MAC, MIC and other 3^rd party payers as requested.
• Proficiency in computer usage including database and spreadsheet analysis, presentation programs, word processing and Internet searching
• Demonstrates adaptability and self-motivation by staying abreast of CMS rules and regulations and incorporating all changes into daily practice.
• Knowledge of federal, state and private payer regulations.
• Working knowledge of quality improvement theory and practice.
• Maintain thorough and current knowledge of clinical care and treatment of assigned patient populations to critically assess appropriateness of documentation.
• Performs all other related duties as assigned.