Clinical Documentation Improvement Specialist - Full Time

• The Clinical Documentation Improvement Specialist facilitates the improvement of the overall quality, completeness and accuracy of medical record documentation. To obtain and promote appropriate clinical documentation through extensive interaction with physicians and other members of the patient care team and coding staff. To ensure Clinical Documentation reflects the level of service, severity of illness and is complete and accurate.

• →Concurrently reviews inpatient admissions to identify opportunities to improve the quality of documentation.
• →Complies with all relevant policies, procedures, guidelines and other regulatory, compliance and accreditation standards.
• →Initiates physician interaction to clarify ambiguous or conflicting documentation and assure any clarification is noted in the patient record according to policy.
• →Maintains positive and open communication with physicians, members of the patient care team, and coding staff.
• →Assumes responsibility for professional development by participating in workshops, conferences and/or in-services.
• →Relates the importance of complete documentation on coding quality, DRG assignment, physician profiling, case mix index and expected mortality rates.
• →Keeps current with changes in coding guidelines, compliance, reimbursement, and other relevant regulatory updates.
• →Understands the general flow of health information from medical record documentation and discharge, coding, billing and finally data reporting.

• Must have one of the certifications/licensures: Doctor of Medicine (MD), Doctor of Osteopathy (DO), Foreign Medical Graduate (FMG), Physician Assistant (PA), Registered Nurse/BSN, RHIA, RHIT, or related clinical allied health degree
• Clinical Documentation Improvement Practitioner (CDIP), Certified Clinical Documentation Specialist (CCDS), Certified Coding Specialist (CCS), or equivalent is a plus
• Minimum 1-year clinical documentation, coding experience in acute care setting.
• Knowledge of ICD-9 or ICD-10 coding, as well as strong computer skills preferred, however content training in coding will be provided.
• Work requires superior interpersonal skills and demonstrated ability to communicate effectively with physicians is essential.

• Work requires a variety of physical activities, including moving about within and outside of all hospital properties for long periods of time.
• Must be able to respond quickly and effectively to emergency and non-emergent situations.
• May be required to assist in controlling disorderly conduct or combative patients.
• Must be able to exchange accurate information with patient, family, peers and medical personnel.
• Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions

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