CDI SPECIALIST - HIM OPERATIONS

North Oaks Health System   Hammond, LA   Full-time     Manufacturing / Production / Operations
Posted on November 13, 2021
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Status:  Full Time

Shift:     Monday - Friday 7:00 a - 3:30 p. Possible rotating weekend coverage.

Exempt: No 

Summary:
Clinical Documentation Improvement Specialist (CDIS) facilitates modifications to clinical documentation through concurrent (pre-bill) interaction with providers and other members of the healthcare team.CDIS promotes capture of clinical severity (later translated into coded data) to support the level of service rendered to relevant patient populations. In addition, theCDIS will:Clinically evaluate how the health record translates into coded data, including review of provider and other clinician documentation, lab results, diagnostic information, and treatment plans.Communicate with providers either through discussion or in writing (e.g., formal queries) regarding missing, unclear, or conflicting health record documentation, and clarify the information as warrantedEducate providers about identification of disease processes that reflect SOI, complexity, and acuity in order to facilitate accurate application of code setsCommunicate with appropriate healthcare team members to promote accurate and complete documentation of diagnoses and/or procedures in the health record that have direct bearing on SOIDemonstrate an understanding of complications, comorbidities, SOI, ROM, case mix, and the impact of procedures on the billed record, as well as the ability to impartthis knowledge to providers and other members of the healthcare teamGather and analyze information pertinent to documentation findings and outcomes, and use this information to develop action plans for process improvements 

Other information:
:1. Previous Experience:a) 3-5 years nursing experience of which a minimum of 2 years were clinical nursing experience. RN, required.Orb) Minimum of 3 years of acute care inpatient coding experience, RHIA or RHIT or CCS required.c) CCDS or CDIP (certified clinical documentation specialist or certified documentation improvement practitioner) in addition to A & B requirements is preferred.2. Specialized or Technical Education· Registered Nurse licensed to practice in the State of Louisiana.or· Graduate of an accredited coding/health information management training program and credentialed.· He or she should also have advanced clinical expertise and extensive knowledge of complex disease processes with broad clinical experience in an inpatient setting.· Knowledge of ICD-9-CM coding, Case Mix Index monitoring, principle diagnosis assignment and legal compliance necessary. Knowledge of CPT coding preferred.· Knowledge of established medical necessity criteria and their application necessary.· Knowledge of Prospective Payment System, DRG’s, other payment methodologies, discharge planning · Knowledge of Peer Review and Fiscal Intermediary Organizations/functions necessary.· Knowledge of third party payor appeal process necessary.· Knowledge of Quality Improvement activities/Team Leader/Facilitator training preferred.3. Manual or Physical Skills Required· Proficiency in organizational skills and planning, with an ability to juggle multiple priorities in a fast-changing environment· Proficiency in computer use, including database and spreadsheet analysis, presentation programs, word processing, and Internet search4. Physical Effort RequiredStrength: SedentaryPush: occasionallyPull: occasionallyCarry: occasionallyLift: occasionallySit: frequentlyStand: frequentlyWalk: frequently

Responsibilities:
A. Responsible for facilitating the improvement in the overall quality, completeness and accuracy of medical record documentation.B. Supports accurate, timely, and complete documentation of clinical information through concurrent coding and interaction with physicians, nursing staff, other patient caregivers, Care Managers, and coding staff to help ensure documentation appropriately reflects the level of acuity of the patient.C. Responsible for assisting physicians and other caregivers responsible for documentation in the medical record to ensure the clinical severity is captured for the level of services rendered to patients with MS-DRG-based payors.D. Responsible for assisting in education of members of the Medical and hospital staff on updates of documentation issues from regulatory agencies.E. Works closely with Health Information Management coding staff to ensure completeness and accuracy of documentation and billed MS-DRG’s.F. Meets at least weekly with coding staff to discuss problematic cases, education, and updates related to documentation.G. Completes MS-DRG initial review within two business days of admission. Follow-up reviews are every 24 hours for cases with queries to physicians and every 48 hours and as needed for all others.H. Assures compliance with regulatory requirements by regular review of regulatory websites and publications.I. Attends department meetings, in-services, workshops, and other educational offerings on Clinical Documentation Improvement topics.J. Participates in hospital education programs as determined by Department Director.K. Follows appropriate departmental policies and procedures related to the Compliant Documentation Management Program.L. Follows North Oaks Health System’s Compliance programs and federal and state regulatory guidelines.M. Other projects or subjects as assigned by the Coding/CDI Director.