Clinical Documentation Improvement CDI Coding Specialist - Careers At Care New England
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Clinical Documentation Improvement (CDI) Coding Specialist
Department:
CNE-FINANCE ADMIN
Operating Unit
Care New England
Location:
Providence, RI
Job ID:
17197
Job Status:
Full Time
Shift:
Days
Schedule:
Mon.-Fri. 7:00am - 3:30pm
Primary Function
The
Clinical Documentation Improvement (CDI) Coding Specialist
is responsible
for
reviewing medical records to facilitate the accurate representation of the severity of illness by improving the quality of the physicians clinical documentation. This involves extensive record review, interaction with physicians, coding professionals, nursing, and case management staffs at Kent Hospital and Women and Infants Hospital.
Specifications
High School Diploma with a minimum of 5 -7 years Coding experience in an acute healthcare environment required.
Certification as a Certified Coding Specialist (CCS) required.
Certified Documentation Integrity provider (CDIP) or Certifed Clinical documentation specialist (CCDS) preferred.
Excellent oral and written skills and knowledge and ability to collaborate with clinical, operational and financial areas required.
Key Competencies
?
Creativity
?
Managing vision and purpose
?
Dealing with ambiguity
?
Planning
?
Innovation management
?
Strategic agility
Application of Knowledge and Skill
Demonstrates a comprehensive, expert-level of knowledge of all procedures concerning the sequencing of diagnoses, procedures including, but not limited to, those outlined in ICD-10-CM/PCS Uniform Hospital Discharge Data Set, Medicare guidelines and other appropriate classification systems. Ensures correct use by the coding staff.
Facilitates necessary documentation in the medical record through extensive interaction with physicians, nursing staff, other patient caregivers, and collaboration with coding staff.
Ensures the accuracy and completeness of clinical information used for measuring and reporting.
Oversees clinical documentation patterns and trends to identify areas of improvement
Educates all members of the patient care team regarding clinical documentation needs, changes to guidelines, coding and reimbursement issues.
Develops and conducts continuous Performance Documentation education for new staff
Compiles, analyzes and evaluates quality and clinical data collected as part of an integrated system-wide program of clinical improvement and documentation requirements.
Gathers and interprets clinical documentation data, to identify discrepancies, problems or issues.
Uses assertive interpersonal skills to discuss clinical documentation issues and work effectively with all levels of internal personnel such as coders, physicians, nursing and case managers
Articulates the program to physician and other health care professionals in order to educate and teach clinical documentation requirements.
Conducts DRG validation and develops effective verbal and written physician queries.
Participates in external reviews such as, Recovery Auditors, and develops written appeals as needed.
Performs other related duties as assigned.
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