Overview:

Under minimal direction, the Clinical Documentation Improvement Specialist will provide active concurrent/

retrospective review, provide feedback, and educate clinical care providers to improve the documentation of all conditions,

treatments, and care plans within the health record to accurately reflect the condition of the patient and promote patient care.

In addition, documentation should reflect documentation associated with MS-DRG assignment, case mix index, severity of

illness, risk of mortality, physician profiling, hospital profiling, and reimbursement rules.

Responsibilities:

Conducts initial and extended-stay concurrent review on selected admissions and documents findings in insert

document/module here (e.g., CDIS module).

Demonstrate successful completion of ongoing proficiency and compliance with regulatory requirements.

Identifies co-morbidities and complications and documents appropriately.

Queries the medical staff and other clinical caregivers as necessary via written/verbal communication to obtain

accurate and complete documentation.

Identifies potential quality, severity of illness, risk of mortality, hospital/physician profiling, and reimbursement

issues or missing documentation.

Communicate documentation issues clearly and succinctly to clinical care providers.

Makes an effort to capture all potential secondary diagnoses.

Act as the liaison between clinical care providers and coding professionals.

Interact with coding team as documentation issues are identified through the coding process for discussion with clinical staff.

Provides ongoing education to physicians and other clinical care providers, related to documentation, changes in coding,

compliance issues, profiling concerns, and reimbursement changes.

Interact with Case Management as they perform admission and continued stay review.

onitor changes in law, regulations, rules, and code assignment that impact documentation and reimbursement

Qualifications:

BSN Preferred.  NC Nursing License.  Five years clinical experience required.   Coding skills with experience in ICD 10 training and working knowledge of the AHA Coding clinic preferred.  Previous experience with clinical documentation preferred.   Certification in CDS preferred.