Clinical Documentation Improvement Specialist

Hours:

Shift Start Time:

7:30 AM

Shift End Time:

4 PM

AWS Hours Requirement:

8/40 - 8 Hour Shift

Additional Shift Information:

Weekend Requirements:

Every Other

On-Call Required:

No

Hourly Pay Range (Minimum - Midpoint - Maximum):

$57.740 - $74.490 - $83.440

The stated pay scale reflects the range that Sharp reasonably expects to pay for this position.  The actual pay rate and pay grade for this position will be dependent on a variety of factors, including an applicant’s years of experience, unique skills and abilities, education, alignment with similar internal candidates, marketplace factors, other requirements for the position, and employer business practices.

What You Will Do

The Clinical Documentation Improvement Specialist (CDIS) reviews inpatient medical records while patients are still in-house (concurrent review) for proper documentation resulting in appropriate reimbursement, severity of illness, risk of mortality, quality measures and risk adjustment. This review includes new admissions to the facility, as well as re-reviews every two to three days until the patients are discharged. The CDIS communicates with clinicians and physicians to ensure timely and accurate documentation for all designated payer(s) and provides training and education as needed. The role collaborates with many departments such as HIM, Quality, and Service lines to improve documentation, reimbursement and Quality measures internally for Sharp Healthcare as well as publicly reported measures.

Required Qualifications

• 5 Years Experience in nursing or other clinical area of an acute care facility
• California Registered Nurse (RN) - CA Board of Registered Nursing -REQUIRED
  
  
  

Preferred Qualifications

• Bachelor's Degree in Nursing
• Emergency or critical care nursing background
• Experience working with an EHR, preferably Cerner Millennium
  
  
  

Other Qualification Requirements

• CDIS certification preferred.
  
  
  

Essential Functions

• Coding compliance
  
  
  

Interacts with Clinical Coding Specialists and Second Level Reviewers to establish a strong, collaborative relationship with the coding team.

Facilitates physician queries and assists in obtaining clinically complete and specific documentation needed for compliant coding.

Assures any clarification is documented appropriately in the patient's record according to policy.

Follows-up with physician, if appropriate.

• Communication and teamwork Demonstrates positive interpersonal relations in dealing with all members of the team (i.e. co-workers, supervisors, physicians, etc.) as evidenced by: communicating in a positive and productive manner; demonstrating respect for team members; maintaining a positive attitude; about assignments and team members; and working collaboratively; and cooperating with other departments/units.
• Documentation Improves accuracy documentation specificity and completeness with real-time interactive communication and education of physicians, clinicians, and other involved parties regarding the necessity of providing complete and clear documentation of the care provided throughout a patient's stay. Includes day to day processes of working daily with physicians to improve documentation capture of diagnosis specificity, all secondary diagnoses, and procedures during the patient stay. Achieved using clinical knowledge to deploy queries, face-to-face communications, and/or other educational programs and tools useful and necessary to achieve this goal.
• Leadership in area of expertise Collaborates with Clinical Informaticists, Physician Informaticists, and Specialists regarding EMR documentation, education and system improvements. Demonstrates content expertise regarding applications and business operations by supporting clients and receiving customer feedback. Manages client expectations, priorities, and attainment of project goals through effective communication. Recommends workflow and technical improvements to various electronic documentation tools.
• Professional development
  
  
  

Abides by all documentation and coding conventions, ethical and professional standards and rules established by the Center for Medicare and Medicaid (CMS), and the American Health Information Management Association (AHIMA) for assignment of diagnostic and procedure codes and ultimately a working DRG.

Adheres to AHIMA query guidelines.

Remains current with coding and documentation improvement techniques to support accuracy of codes and the resulting working DRG assigned.

Participates in educational programs and in-services in order to maintain and exceed excellence in documentation and coding skills.

Information will include the AHA Coding Clinic publication, pharmacology, laboratory, disease processes, and new/emerging technologies.

Participates in the peer review process as both a reviewer and reviewee as a means of education and feedback to peers and self.

• Quality
  
  
  

Collaborates with the Quality Team to determine if documentation supports or negates an AHRQ patient Safety indicator and or Hospital Acquired Condition

Reviews record to identify appropriate risk adjustment diagnoses which are relevant and may impact the scoring or quality of the documentation

Knowledge, Skills, And Abilities

• Strong clinical skills including understanding of clinical disease process, pathophysiology and treatment plans.
• Effective interpersonal skills in order to interact effectively with physicians and all levels of hospital personnel.
• Organization and prioritization skills.
• Effective written and verbal communications skills.
• Analytical skills.
• Working knowledge of regulatory coding guidelines preferred.
• Proficient with MS Office applications.
  
  
  

Sharp HealthCare is an equal opportunity/affirmative action employer. All qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, gender, gender identity, sexual orientation, age, status as a protected veteran, among other things, or status as a qualified individual with disability or any other protected class