Clinical Documentation Specialist-III Inpatient

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Responsible for strategic management of service line integration throughout the system. Capable of focused and second level reviews. Performs independently at the highest level of expectation. Assists Manager on specific projects as assigned. MINIMUM QUALIFICATIONS :

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

1. Certification in ONE of the Following:

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Certified Documentation Integrity Practitioner (CDIP) through the American Health Information Management Association (AHIMA)

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Certified Clinical Documentation Specialist (CCDS) through the Association of Clinical Documentation Integrity Specialists (ACDIS)

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Certified Documentation Expert Inpatient (CDEI) through the American Association of Professional Coders (AAPC)

EXPERIENCE:

1. Three (3) years Inpatient acute care coding experience OR

Three (3) years clinical RN experience in Inpatient acute care setting OR

Three (3) of clinical LPN experience in Inpatient acute care setting.

2. Five (5) years of experience in Clinical Documentation Integrity.

CORE DUTIES AND RESPONSIBILITIES: The statements described here are intended to describe the general nature of work being performed by people assigned to this position. They are not intended to be constructed as an all-inclusive list of all responsibilities and duties. Other duties may be assigned.

1. Assists CDI Manager in the planning, execution, and delivery of a high-quality CDI department.

2. Assists CDI Manager in the design, collection, and reporting of relevant data to support the System CDI Program.

3. Collaborates with CDI Educator/Manager for provider educational opportunities.

4. As a CDI system service line expert, responsible for integration and strategic management of service line, keeping the service line team focused on CDI greatest impact.

5. Attends all revenue integrity meetings related to their designated system service line.

6. Capable of efficient review and timely results for focused DRGs and second level reviews.

7. In collaboration with the providers and staff, identifies and records principle diagnoses, secondary diagnoses, procedures, and assigns a working Diagnostic Related Group (DRG).

8. Conducts initial concurrent review and ongoing re-reviews for all selected admissions by documenting findings regarding DRGs, APR-DRGs and Value Based Purchasing/Quality measures.

9. Identifies need to clarify documentation through quality audits in records and initiates communication with physician, nurse, or patient care coordinator by utilizing the appropriate “query” tools in order to capture the documentation in the medical record that accurately supports the patient’s severity of illness.

10. Provides information and ongoing education as necessary to providers and staff on documentation issues, guidelines, and unanswered queries

11. Promotes compliance with CMS, Medicare documentation, and coding and billing regulations.

12. Participates in the processes to assess and improve the services provided and compliance with regulatory requirements. Report results assessment and improvement processes to the appropriate administrative levels.

13. Collaborate with the Quality Department to ensure documentation meets quality initiative standards used for measuring and reporting hospital and provider outcomes.

14. Collects, analyzes and submits timely, accurate and complete reports of clinical documentation information used for measuring and reporting Hospital and Provider outcomes data.

15. Works with the Coding Specialists on any issues that arise concerning documentation, providers, and queries to enhance the concurrent process to enable prompt coding.

16. Serves as a mentor an