HIM002 Clinical Documentation Improvement Specialist

Position Summary

The Clinical Documentation Improvement Specialist (CDIS) implements clinical documentation improvement (CDI) activities in an effort to support accuracy and quality of patient records at South Arkansas Regional Hospital to ensure that coded diagnoses are an accurate reflection of the patient's clinical status and care. The role of the CDI specialist involves reviewing the medical record documentation, and clinical indicators and working with providers to ensure a complete and accurate medical record. An accurate medical record is important for the patient, for continuity of care by the next provider, and to demonstrate high quality care by the physician and the hospital. The CDI specialist will identify potential gaps in clinical documentation for patient and payer populations as directed throughout the hospitalization. He/she will also educate physicians and key healthcare providers regarding clinical documentation improvement and the need for accurate and complete documentation in the health record. 

License Required: One of the following RN, RHIA, RHIT, MD, DO, CCS

Education: Master's Degree preferred

Experience: One to Four years of either acute hospital clinical/nursing experience (e.g. ICU, Med/Surge, OR) or coding experience is required. Five years of more experice is preferred.

Previous Experience working in a clinical documentation improvement department, as a consultant, or in auditing preferred

Previous experience in clinical documentation improvement, ICD coding and MS-DRGs preferred

Prior experience educating physicians/providers preferred

Previous Experience in Utilization Management/Case Management, ICU/Critical Care, patient outcomes/quality management and/or inpatient coding strongly desired. 

Essential Job Functions

To perform this job successfully, an individual must be able to perform each of the following Essential Duties satisfactorily.  Reasonable Accommodations may be made to enable qualified individuals with disabilities to perform the Essential Duties of the position, provided it does not create undue hardship on SARH.

• Provides expert level review of inpatient clinical records within 24-28 hours of admit.
• Conducts follow up reviews every 48-72 hours or as needed.
• Identifies gaps in clinical documentation that need clarification for accurate code assignment to ensure the documentation accurately reflects the severity of the patient condition and acuity of care provided.
• Conducts daily follow up communication with providers regarding the existing clarifications to obtain needed documentation specificity.
• Effectively articulates recommendations for improvement and the rational for the recommendation.
• Actively communicates with providers at all levels to clarify information and to communicate documentation requirements for appropriate diagnoses based on severity of illness and risk or mortality. 
• Provides complete follow through on all requests for clarification or recommendations for documentation improvement.
• Leads the development and execution of physician education strategies resulting in improved clinical documentation .
• Provides timely feedback to providers regarding clinical opportunities for improvement and successes.
• Ensures effective utilization of Clinical Documentation Improvement software.
• Documents and reports all verbal, written and electronic clarification activity.
• Tracks and reports all CDI activities and ensures that CDI impact is reported accurately and promptly.
• Utilizes only the CHS approved query forms whether paper or electronic.
• Ensures all queries issued are necessary compliant and non-leading.
• Proactively develops a reciprocal relationship with the Coding Professionals to ensure accuracy of diagnostic and procedural data through completeness of supporting documentation
• Collaborates with case managers, nursing staff, ancillary staff and all members of the interdisciplinary care team.
• Adheres to official coding compliance regulations, SARH policies developed to ensure accurate billing and industry best practice clinical documentation principles. 
• Keeps abreast of regulatory changes related to inpatient coding and documentation and communicates these changes to appropriate corporate and hospital staff.
• Possess the ability to develop and present effective education utilizing a variety of media platforms
• Completes other duties as assigned. 

This job description is a summary of the typical functions of the job, not an exhaustive or comprehensive list of all the possible job responsibilities, tasks, and duties you may be asked to perform when they are assigned.