Position Summary

Under general supervision of the Clinical Documentation Integrity Program Manager, the Clinical Documentation Specialist II is responsible for improving overall quality and completeness of clinical documentation to accurately reflect patient severity of illness and risk of mortality through extensive interaction with physician, case management, nursing staff, other patient caregivers and coding staff. Ensures the accuracy and completeness of clinical information used for measuring and reporting physician outcomes.

POSITION ACCOUNTABILITIES AND PERFORMANCE CRITERIA

1. Initiates and performs concurrent documentation review of selected inpatient records to clarify conditions/diagnosis and procedures where inadequate or conflicting documentation is suspected. Meets or exceeds defined performance standards for chart reviews and queries.
2. Improves coding specificity by educating physicians, clinicians, and other involved parties regarding the necessity of providing complete and clear documentation of the care provided throughout a patient’s stay. This includes capturing complications/co-morbidities during the patient’s stay. This is achieved via queries, face-to-face communications, and/or other educational programs and tools useful and necessary to achieve this goal. Serves as a resource for physicians to help link ICD-10-CM coding guidelines and medical terminology to improve accuracy of final code assignment.
3. Follows guidelines for coding and documentation to ensure physician and hospital compliance. Remains current with coding information to ensure accuracy of codes assigned base on documentation. Participates in educational programs and in-services in order to maintain and exceed excellence in coding skills.
4. Performs ongoing CDI Final Review/DRG Reconciliation and reports DRG mismatch disagreements for secondary review as defined.
5. Performs ongoing query reconciliation as defined, with regular monitoring of query outcomes for query performance opportunities.
6. Utilize and thrive in CDI technology and follow established standardized process flow.
7. Maintain open communication with coding to discuss DRG assignment, diagnosis, clinical indicators, coding clinics and guidelines and educating each other on the specialty.
8. Assign Working DRG for Case Management department to view the Length of Stay (LOS) of patients.
9. Pass annual analysis and evaluation.
10. Participate and provide input regarding CDI program activities, and attendance at routine team meetings.
11. Maintain current skill set regarding government regulations, compliance and reimbursement guidelines.
12. Expected to keep abreast of new legislation and regulations that affect CDI.
13. Maintain personal and professional education and growth.
14. Responsible for maintaining continuing education credits as required by credentialing organization.
15. Identifies, assists, and participates in inter/intra-departmental special projects involving the accuracy of physician documentation.
16. Collaborates with the Physician Advisor in identifying patterns of physician documentation issues, utilization/follow up of queries and education of physicians at the bedside and/or monthly meetings
17. Maintains established hospital and departmental policies and procedures, objectives, performance improvement program, safety, environmental and infection control standards. Maintains confidentiality and security levels to protect medical/legal patient care documentation.
18. Participates in training and mentoring of new team members
19. Other duties as assigned.
20. Responsible for complying with all policies and procedures that pertain to HIPAA including the minimum necessary requirements for this job position. As part of the requirements for this position, the employee:

Has access to the entire medical record for the purpose of performing concurrent and post-care clinical review, obtaining relevant data to meet federal, state and local reporting requirements, and to gather relevant clinical information to facilitate patients through the continuum of care.

In this position, the employee will limit the PHI disclosed or requested to the minimum amount reasonably necessary to achieve the purpose of the request. The disclosures or requests that occur on a routine or recurring basis include clinical, demographic and financial information.

The employee makes these disclosures for the purpose of meeting data reporting obligations and/or insuring patients receive access to appropriate clinical services throughout the continuum of care.

Criteria established to limit the PHI disclosures/ requests to that which is reasonably necessary includes:

** Sending only information that is required to meet the criteria established by AHCA and other Federal, State, Local or Accrediting Agencies;

** Limiting patient information sent for purposes of managing the continuum of care to the minimum required to properly assess the needs of patients and facilitate access to appropriate services

21.Performs and fulfills all HICS (hospital incident command system) responsibilities, assignments, tasks, and roles as directed and needed by the facility in times of emergency and/or disaster. Responsible for knowing the Hospital’s emergency codes, including the purpose and appropriate action for each, and adheres to the Hospital policies and procedures for each emergency code.

POSITION QUALIFICATIONS:

EDUCATION REQUIREMENT:

Required: Graduate of a foreign medical school or education recognized by the State of Florida as qualification for licensed Registered Nurse, LPN, Physician Assistant, or Advanced Practice Registered Nurse

Desirable: MBA, MPH, MHA or MSN

REQUIRED LICENSURE/REGISTRATION/CERTIFICATIONS:

• Must be either: licensed in the State of Florida as a Registered Nurse, LPN, Physician Assistant or APRN licensed in the State of Florida or a graduate of a foreign medical school (with ECFMG Certification preferred but not required)
• Certified in one of the following within 2 years of hire into the position:
  • Certification in clinical documentation improvement through ACDIS or AHIMA (CCDS or CDIP) strongly desired.
  • Certified in coding (CCS) preferred.

EXPERIENCE:

Minimum of 2 years clinical or inpatient experience in an acute care setting required; 5 years strongly preffered.

OTHER QUALIFICATIONS:

• Famililarity with coding concepts and coding software desired.
• Knowledge of care delivery documentation systems and related medical record documents.
• Knowledge of age-specific needs and the elements of disease processes and related procedures.
• Strong broad-based clinical knowledge and understanding of pathology/physiology of disease processes.
• Excellent written and verbal communication skills.
• Excellent critical thinking skills.
• Excellent interpersonal skills to build effective partnering relationships with physicians, nurse staff and hospital management staff, and health information systems coding staff.
• Working knowledge of inpatient admission criteria.
• Ability to work independently in a time-sensitive environment.
• Computer literacy and familiarity with the operation of basic office equipment.
• Assertive personality traits to facilitate ongoing physician communication.
• Ability to stand and walk for periods of time is required in the performance of job responsibilities.
• Working knowledge of MS DRGs and national coding guidelines.

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Tenet complies with federal, state, and/or local laws regarding mandatory vaccination of its workforce. If you are offered this position and must be vaccinated under any applicable law, you will be required to show proof of full vaccination or obtain an approval of a religious or medical exemption prior to your start date. If you receive an exemption from the vaccination requirement, you will be required to submit to regular testing in accordance with the law.