Clinical Documentation Improvement Specialist

The Clinical Documentation Improvement Specialist (CDIS) is responsible for educating clinical staff, improving documentation of all conditions, treatments, and care plans to ensure the highest quality of care is provided to the patient.

Essential Functions:

• Understand and comply with the laws and regulations governing my job activities and the ethical and legal standards set forth in the Nor-Lea Compliance Program Plan and Code of Conduct.
• Evaluates medical record documentation and coding to optimize reimbursement by ensuring that diagnostic and procedural codes and other documentation accurately reflect and support visits and to ensure that data complies with legal standards and guidelines.
• Make recommendations for changes in policies and procedures.
• Educates and advises staff on proper code selection, documentation, procedures, and requirements.
• Identifies training needs, prepares training materials, and conducts training for physicians and support staff to improve skills in the collection and coding of quality health data.
• Assist in ensuring Quarterly provider E/M audits are performed, reported and follow-up education is performed.
• Responds and assists customers immediately upon request and follows up on previous interactions to ensure issue resolution, escalation, or issue closure as appropriate.
• Serves as subject matter expert (SME) of Clinical Documentation. Assist, investigate, and solve documentation concerns with recommendations to clinical departments and hospital staff.
• Able to effectively communicate with other end users and is perceived as approachable and reliable.

SKILLS, KNOWLEDGE AND ABILITIES

• • Ability to effectively build relationships with customers through positive interaction
  • Ability to work independently
  • Ability to prioritize responsibilities and to organize workload to ensure that timeframes are met
  • Problem solving
  • Ability to develop training materials, make group presentations, and to train staff

• • Knowledge of ICD-10-CM and CPT coding guidelines; medical terminology; anatomy and physiology; state and federal Medicare reimbursement guidelines
  • Ability to identify, analyze, and effectively address complex issues
• MINIMUM EXPERIENCE REQUIRED
• • 2 years working in an EPIC or other EHR environment
• MINIMUM EDUCATION REQUIRED
• • High School Diploma or General Education Degree Required
• LICENSURE/CERTIFICATION PREFERRED (must initiate continued education within 6months of hire)
• • Certification in Clinical Documentation Improvement preferred
  • Certification in Coding preferred
  • Associate of Applied Science