Job: Clinical Documentation Improvement Specialist

Collaborates extensively with physicians, nursing staff, and other patient care givers, and HIM coding staff to improve quality and completeness of documentation of care provided and coded. Facilitates concurrent modifications to clinical documentation to ensure commensurate reimbursement of clinical severity and services rendered to patients with a DRG based payor. Supports timely, accurate and complete documentation of clinical information used for measuring and reporting physician and facility outcomes. Educates all members of the patient care team on an ongoing basis, including issue focused education sessions. Assists with medical necessity assessments as requested. Performs focused reviews/chart audits at the discretion of the HIM Director or Case Management Director.

Duties: Reviews all inpatient and observation, DRG-based payor patient records to assure clinical documentation is complete, accurate and supports level of care, promoting patient safety, quality and continuity of care and ensuring proper reimbursement for patient services.

Demonstrates knowledge of DRG payor issues and documentation requirements.

Conducts timely follow-up reviews of clinical documentation to ensure issues have been discussed and clarified with physician and have been recorded in the patient’s medical record.

Reviews clinical issues as needed with coding staff.

Develops and conducts ongoing clinical documentation education and training for physicians, nursing and allied health professionals under the guidance of the HIM Director, Case Management Director and/or Clinical Education Director.

Maintains positive, open communication with physicians, case management, coding team, and clinical staff.

Assists in medical necessity screening process, collaborating with Case Management to ensure continuity of patient care and validation of documentation with plan of care. Verifies patient admission status remains accurate throughout admission and prior to patient discharge.

Conducts focused chart audits and reviews at the discretion of the HIM Director or Case Management Director.

Performs in a manner consistent with the organizations Corporate Compliance Plan and Code of Conduct.

Education – Registered Nurse, BSN preferred.

Training and Experience: 5 years recent clinical experience in a hospital setting.

Job Knowledge: Clinical, ICD-9 coding and DRG assignment.