What are the responsibilities and job description for the CDI Specialist position at Memorial Hospital of Sweetwater County?

- MHSC is an equal employment opportunity employer and does not discriminate on the basis of gender, age, race, color, creed, religion, national origin, marital status, sexual orientation, gender identity, mental or physical disability or uniformed services status. MHSC is dedicated to fostering an inclusive environment that recognizes the contributions and supports the advancement of all because an inclusive environment can enhance the quality of healthcare, improve hospital/community relations, and positively affect the health status of society. No candidate will be rejected based on any of the above or any disability that, with reasonable accommodation, does not prevent performance of the essential job duties.
- MHSC is committed to the "Planetree" methodology of "Person-Centered Care". Person-Centered Care is more than hospitality. It is more than amenities and inviting surroundings. Person-Centered Care is an evidence-based framework for improved patient and family engagement, better clinical outcomes, increased staff retention/ recruitment, and high value care. Person-Centered Care creates workplaces that energize and inspire joy. It places patients and caregivers at the center of the care experience and unites communities around health and wellness. This approach also focuses on supporting the professional and personal aspirations of healthcare professionals who can more effectively care for others when they feel cared for themselves.
JOB SUMMARY
- The Clinical Documentation Improvement Coordinator (CDIC) at Memorial Hospital of Sweetwater County (MHSC) works within the entirety of the organization to review and monitor documentation processes for improvement. The professional in this position collaborates with providers, clinical care professionals in all disciplines, and health information management professionals to improve the quality and completeness of care provided to patients. The CDIC facilitates concurrent modifications to clinical documentation to insure reimbursement of clinical severity and services rendered to patients with a DRG based payer (Medicare or Medicaid and other insurers using this system). The CDIC supports timely, accurate and complete documentation of clinical information used for measuring and reporting provider and facility outcomes. The CDIC has the skills and ability to educate all members of the patient care team about clinical documentation improvement on an ongoing basis.
JOB QUALIFICATIONS
- Education:
  - High School diploma or equivalent is required. The CDIC is a registered nurse and licensed as such under the Wyoming State Board of Nursing. The RN must have graduated from an accredited school of nursing. BSN required, Masters preferred. Must be willing to obtain the Certified Clinical Documentation Specialist (CCDS) within 3 years of hire.
- Job Knowledge and Skills:
  - At minimum of 5 years of advanced clinical expertise and extensive knowledge of complex disease processes with broad clinical experience in an inpatient setting, ICU or ED experience preferred. ICD coding experience, case management, and utilization review experience are a plus.
    
    1. Ability to work independently, is self-directed and self-motivated with the need for minimal guidance, and adapt to the changing healthcare arena.
    2. Excellent verbal and written communication skills, analytical thinking, and problem solving with strong attention to detail.
    3. Proficiency in organizational skills and planning, with an ability to juggle multiple priorities in a fast-changing environment.
    4. Proficiency in computer use, including database and spreadsheet analysis, presentation programs, word processing, and Internet searches.
    5. Knowledge of federal, state, and private payer regulations as well as applicable organizational policies and procedures.
    6. Working knowledge of quality improvement theory and practice, core measures, safety, and other required reporting programs.
    7. Ability and willingness to seek out changes in healthcare reform and coding regulations, and then incorporate those changes into chart review and educational responsibilities.
    8. Participation in professional nursing organizations, such as the Wyoming Nurses Association, American Nurses Association, the Association of Clinical Documentation Improvement Specialists and/or similar professional organizations is an expectation in this role.
    
    Role Functions:
    1. Review inpatient medical records, concurrent with patient, stay to identify opportunities to clarify missing or incomplete documentation.
    2. Collaborate with providers, case managers, care transition and chronic care management staff and nurses, coders, and other healthcare team members to facilitate comprehensive health record documentation that reflects clinical treatment, decisions, diagnoses, and interventions.
    3. Use the organization's designated clinical documentation systems to conduct reviews of the health record and identify opportunities for clarification.
    4. Conduct follow-up of posted queries to ensure that queries have been answered and provider responses have been appropriately documented.
    5. Provide or coordinate education related to compliance, coding, and clinical documentation issues within the healthcare organization. This may include rounding with the multidisciplinary healthcare team.
    6. Act as a consultant to coding professionals when additional information or documentation is needed to assign coded data.
    7. Play a pivotal role on the Utilization Management Team in leading utilization management efforts.
    8. Collaborate with HIM/coding professionals to review individual problematic cases and ensure accuracy of final coded data in conjunction with case managers, care transition and chronic care coordination staff and professionals, coding managers, and/or provider advisors.
    9. Gather and analyze information pertinent to documentation findings and outcomes.
    10. Contribute to a positive working environment and perform other duties as assigned or directed to enhance the overall efforts of the organization.
    11. Develop provider education strategies to promote complete and accurate clinical documentation and correct negative trends.
    12. Identify patterns, trends, variances, and opportunities to improve documentation review processes.
    13. Assist in the development and reporting of performance measures to the medical staff and other departments and prepare physician-specific data information.
    14. Enhance expertise in query development and presentation.
    15. Conduct independent research to promote knowledge of clinical topics, coding guidelines, regulatory policies and trends, and healthcare economics.
    
    Must possess the following skills:
    1. Essential technical/motor skills-requires excellent observation and assessment skills, analytical thinking, problem solving and good verbal and written communication.
    2. Interpersonal skills: Professional demeanor, a team player, able to communicate well with others. Regular contacts with other personnel throughout and outside the organization.
    3. Essential knowledge abilities: Expert clinical reasoning skills of noticing and interpreting; able to expertly apply the nursing process; applies adult-teaching learning principles at the proficient or expert levels. Able to work within a variety of databases and electronic medical record systems. Working knowledge of acutely ill, critically ill and chronically ill patients and their clinical diagnoses and care needs based on expert knowledge of pathophysiology, pharmacology and the current system of health care.

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