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Clinical Documentation Specialist

1 month ago

GondrecourtleChâteau, Grand Est, United States Fairview Health Services Full time
Job Summary

We are seeking a highly skilled Clinical Documentation Integrity Specialist to join our team at Fairview Health Services. This advanced-level position will utilize ICD-10-CM and ICD-10 PCS Coding Classification systems to design, implement, and monitor facility physician education around clinical documentation integrity.

Key Responsibilities
  • Work with providers, advance practice practitioners, clinical departments, CDI, and Coding staff to accurately document and report patient medical conditions and illness severity.
  • Educate staff to improve performance on risk-adjusted CMS mortality measures and monitor metrics to identify areas of growth opportunity.
  • Monitor reimbursement impact after education.
  • Educate providers on documentation guidelines.
  • Assist in physician documentation templates for diagnosis and procedures.
  • Capture and report educational time metrics.
  • Analyze data, documentation, and workflows related to quality and accuracy of CDI staff work and provider documentation performance.
  • Complete quality assurance checks on CDI Specialists basis based on best practice and report findings regularly.
  • Create and present educational content for CDI staff in coordination with CDI leadership.
  • Create and present educational content for providers (orientation and ongoing education).
  • Coordinate with program administrators to schedule orientation sessions for provider onboarding.
  • Maintain an advanced level of understanding related to CDI and HB Coding rules and compliance.
  • Attend and complete educational sessions and webinars as appropriate to support personal understanding.
  • Cascade pertinent information from these sessions to the CDI staff.
  • Actively participate in CDI workstreams and improvement tasks as assigned.
  • Support and assist CDI staff during backlogs or as assigned.
Requirements
  • Associate degree (or higher) in Nursing or Health Information Management (HIM) degree or related field or equivalent experience.
  • At least 2 years as a Clinical Documentation Integrity (CDI) Specialist.
  • One of the following: RHIT, RHIA or RN.
Preferred Qualifications
  • Bachelor's degree (or higher) in Nursing or Health Information Management (HIM) or related field or equivalent experience.
  • 5 years of experience as a Clinical Documentation Integrity (CDI) Specialist.
  • One of the following: RN, CCDS, CDIS, CDIP, CDEI, CCS, CPC, CCDSO or CCIO.
Additional Requirements
  • Knowledge of clinical documentation requirements related to regulatory and reimbursement rules and regulations.
  • Knowledge of medical terminology, anatomy and pathophysiology, pharmacology, ancillary test results.
  • Knowledge of ICD-10-CM and DRG classification systems.
  • Knowledge of physician and nursing unit practices.
  • Excellent interpersonal, analytical critical thinking, problem-solving, and conflict management skills to foster a positive working environment.
  • Strong attention to detail.
  • Ability to enter data, track, and reconcile sensitive material with minimal errors.
  • Ability to problem-solve, work independently, prioritize multiple tasks, identify process improvement opportunities.
  • Excellent verbal and written communication skills.