What are the responsibilities and job description for the Clinical Documentation Integrity Specialist position at Children's Hospital of The King's Daughters?
Summary
- Monday-Friday 7:30 AM - 4:00 PM
- GENERAL SUMMARY
- The Clinical Documentation Integrity Specialist is responsible for reviewing inpatient medical records to assess and procure accurate and complete documentation of the patients’ diagnosis and procedures. Reports to department leadership.
- ESSENTIAL DUTIES AND RESPONSIBILITIES
- Reviews Inpatient Clinical Documentation, ensuring that physicians’ and clinicians’ documentation, accurately reflect the patient’s conditions, diagnoses, treatments, and interventions, resulting in accurate reimbursement.
- Reviews to ensure the clinical documentation, reflects the patient’s severity of illness, quality of care and resources used.
- Provides education to the physicians and ancillary providers regarding accurate, specific and compliant clinical documentation.
- Acts as a resource for other departments regarding the importance of clinical documentation integrity, and the need to clinically document following the Federal and State regulations.
- Performs all other duties as assigned.
- LICENSES AND/OR CERTIFICATIONS
- Required Licenses and/or Certifications
- Current Virginia state license as a Registered Nurse or Registered Nurse holding a valid Compact State license required.
- Preferred Licenses and/or Certifications
- Certified Documentation Improvement Professional (CDIP) or Certified Clinical Documentation Specialist (CCDS) certification or must be credentialed through AHIMA or ACDIS, within two years of start preferred.
- MINIMUM EDUCATION AND EXPERIENCE REQUIREMENTS
- Required Education and Experience
- Registered Nurse -Professional knowledge of nursing theory and practice at a level normally acquired through the completion of an accredited School of Nursing.
- Preferred Education and Experience
- BSN preferred.
- Pediatric and or Clinical Documentation or Utilization Management preferred.
- Required Knowledge, Skills and Abilities
- Experience with applying clinical criteria to a medical record review with a Clinical Documentation Integrity focus.
- Knowledge of healthcare payment systems, specifically the MS-DRG, Tricare and APR-DRG reimbursement systems.
- Ability to form positive and collaborative relationships, with Physicians, HIM colleagues, the Physician Advisor and other hospital staff.
- Competent using Microsoft Office Suite, and different Electronic Medical Records.
- Requires Strong organizational, clinical critical thinking and analytical skills.
- Preferred Knowledge, Skills and Abilities
- Technical and professional knowledge and skills for clinical operations of the service area, usually acquired through 3 - 5 years’ progressive Clinical/Supervisory experience in a practice setting.
- WORKING CONDITIONS
- Normal office environment with little exposure to excessive noise, dust, temperature and the like.
- PHYSICAL REQUIREMENTS
- Click here to view physical requirements.