What are the responsibilities and job description for the Clinical Documentation Improvement Spec. position at BJC HealthCare?

Additional Information About the Role

BJC HealthCare is seeking a Clinical Documentation Improvement Specialist to support Barnes Jewish Hospital to join our team!

Ideal applicants will have a background in CDI or ICU nursing.

Overview

Barnes-Jewish Hospital at Washington University Medical Center is the largest hospital in Missouri and is ranked as one of the nation's top hospitals by U.S. News & World Report. Barnes-Jewish Hospital's staff is composed of full-time academic faculty and community physicians of Washington University School of Medicine, supported by a house staff of residents, interns, fellows and other medical professionals. Recognizing its excellence in nursing care, Barnes-Jewish Hospital was the first adult hospital in Missouri to be certified as a Magnet Hospital by the American Nurses Credentialing Center.

Preferred Qualifications

Role Purpose

The Clinical Documentation Improvement Specialist I (CDIS I) uses clinical and coding knowledge for conducting clinically based concurrent and retrospective reviews of both inpatient and outpatient medical records reviews to evaluate the clinical documentation of clinical services by identifying opportunities for improving the quality of medical record documentation. This position facilitates and obtains appropriate physician documentation for any clinical conditions or procedures to support the appropriate severity of illness, expected risk of mortality, and complexity of care of the patient.

Responsibilities

Reviews clinical documentation to facilitate the accurate representation of the severity of illness, expected risk of mortality, and complexity of care by improving the quality of the physician’s clinical documentation.

Utilizes hospital coding code set, policies and procedures, federal and state coding reimbursement guidelines, and application of the Coding Clinic Guidelines to assign working diagnosis-related groups (DRG); review patient records throughout hospitalization that have been identified as focus DRG by regulatory agencies or the facility to ensure the codes are reported at the highest specificity.

Initiates physician interaction when abnormal ancillary test findings, ambiguous, missing or conflicting information is in the medical record, through the physician query process and/or participation in rounding with the physicians by requesting additional documentation for correct coding and compliance necessary for accurate reflection of CMI, LOS, and optimal resource utilization.

Partners with other healthcare disciplines and HIMS coding staff to ensure accuracy of diagnostic and procedural data and completeness of supporting documentation to reconcile the working and final DRG, severity of illness, risk of mortality and quality outcomes.

Initiates medical record review within 24 to 48 hours of admission; sytematically monitors the targeted medical records within at least 48 hours (unless otherwise indicated) to determine compliance to established documentation standards; conducts follow-up reviews to ensure points of clarification have been addressed/documented in the medical record.

BJC has determined this is a safety-sensitive position. The ability to work in a constant state of alertness and in a safe manner is an essential function of this job.

Minimum Requirements

Education

Nursing Diploma/Associate's

- Nursing

Experience

2-5 years

Licenses & Certifications

Preferred Requirements

Education

Bachelor's Degree

- Nursing

Experience

5-10 years

Supervisor Experience

No Experience

Benefits and Legal Statement

BJC Total Rewards

At BJC we’re committed to providing you and your family with benefits and resources to help you manage your physical, emotional, social and financial well-being.

Comprehensive medical, dental, vison, life insurance, and legal services available first day of the month after hire date
Disability insurance* paid for by BJC
Annual 4% BJC Automatic Retirement Contribution
401(k) plan with BJC match
Tuition Assistance available on first day
BJC Institute for Learning and Development
Health Care and Dependent Care Flexible Spending Accounts
Paid Time Off benefit combines vacation, sick days, holidays and personal time
Adoption assistance

To learn more, go to our Benefits Summary.

*Not all benefits apply to all jobs

The above information on this description has been designed to indicate the general nature and level of work performed by employees in this position. It is not designed to contain or be interpreted as an exhaustive list of all responsibilities, duties and qualifications required of employees assigned to this job. Equal Opportunity Employer

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Clinical Documentation Improvement Spec.

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