Position SummaryThe Clinical Documentation Specialist facilitates the improvement in the overall quality, completeness, and accuracy of clinical documentation in the medical record. Obtains appropriate clinical documentation through extensive interaction with physicians, nursing staff, and Health Information Management coding staff. Ensures that the clinical severity and risk of mortality for the level of services provided are appropriately documented for inpatient accounts. Educates members of the patient care team on documentation guidelines on an ongoing basis.

Duties & Responsibilities

Essential Responsibilities
Clinical Documentation Improvement/Quality/Education
Facilitates appropriate clinical documentation to ensure that the level of services and acuity of illness are accurately reflected in the medical record.
Improves overall quality and completeness of clinical documentation for identified patient populations.
Demonstrates knowledge of MS-DRG and APR-DRG payer issues, documentation opportunities, clinical documentation requirements, coding, policies and procedures, and quality measures.
Improves the overall quality and completeness of clinical documentation by performing admission/continued stay reviews using clinical documentation guidelines for selected patient populations.
Formulates compliant and credible clinical documentation clarifications or queries to improve clinical documentation of principal diagnosis, co-morbidities, clinical severity and risk of mortality, present on admission (POA), quality core measures, and patient safety indicators (PSI).
Updates worksheet to reflect any changes in patient status, procedures/treatments, and confers with the physician to finalize diagnoses as required.
Conducts timely follow-up reviews of clinical documentation to ensure issues discussed and clarified with the physician have been recorded in the patient’s chart.
Collaborates with the coding staff concurrently and retrospectively and reviews clinical issues as needed with the Coding Staff for the accuracy of coding.
Responsible for accurate, timely entry of pertinent data.
Assumes the responsibility for achieving program objectives.
Maintains positive communication with physicians, CDI team members, and management.
Assists in special projects as required.
Collaborates with other nurses and physicians to identify, promote, and provide positive learning experiences for providers.
Provides CDI education to nursing staff, and Allied Health Professionals as appropriate.
Initiates one-on-one physician education interaction as indicated for clarification and documentation needs.
Assists in the development of educational presentations to medical providers for awareness of documentation requirements.
Provides clinical information and education to coding staff as needed.
Assists Clinical Documentation Improvement Director in providing education to Physician Liaisons regarding medical payment systems, coding rules, and healthcare reporting.
Professional/Leadership
Participates in organizational, departmental, and shared leadership activities; supports department goals in daily behavior.
Demonstrates accountability for job performance by (1) seeking opportunities to enhance job skills and knowledge; and (2) maintaining conditions of employment (RN licensure, CCDS, and other required certifications).
Demonstrates a broad scope of clinical expertise.
Demonstrates effective time management skills.
As needed, recommends quality and/or performance improvement initiatives to more effectively and efficiently perform job functions.
Accesses Medical Center intranet for relevant communication and to review and interpret changes in policy, procedure, and other information pertinent to the role.
Takes responsibility for continued professional growth/development by identifying learning needs and initiating strategies to meet such needs.
Stays current with ongoing clinical documentation education.
Maintains professional growth by participating in conferences, professional development courses, etc.
Performs other job functions related to this job, as assigned.
Organizational
Adheres to the UI Health’s Code of Conduct.
Treats patients/families, staff, students, and visitors with respect and dignity.
Adheres to Nursing’s time, overtime, and attendance policies.
Completes electronic learning modules and related programs as assigned by UI Health by established date.
Complies with University Health Services TB and fit-testing requirements.
Utilizes established communication channels/chain of command to escalate or resolve patient care problems.
Identifies recurring clinical practice and/or related unit problems and participates in problem-solving and resolution.
Reporting Structure
This person works independently within the scope of the Clinical Documentation Improvement Program. The CDI Director, acting as coach and mentor, provides direction, guidance, and feedback regarding practice and performance. The employee’s performance is evaluated annually in writing and more frequently if needed. The employee and the Director meet on an as-needed basis for coaching and mentoring where support, guidance, and direction can be given.