Clinical Documentation Improvement Specialist

4 weeks ago


White Plains, New York, United States White Plains Hospital Full time
Job Summary

The Clinical Documentation Improvement Specialist plays a crucial role in ensuring the accuracy and quality of medical records. This position involves extensive review of medical records, interaction with physicians, health information management professionals, and nursing staff. The successful candidate will be an active participant in team meetings and education of staff in the Clinical Documentation Improvement Program (CDIP) process.

Key Responsibilities
  1. Review medical records for completeness and accuracy, utilizing the Compliant Documentation Management Program documentation strategies.
  2. Perform accurate and timely record review, recognizing opportunities for documentation improvement.
  3. Initiate severity illness worksheets for inpatient cases and formulate clinically credible documentation clarifications (queries).
  4. Request documentation clarifications as appropriate for SOI, Core Measures, and Patient Safety.
  5. Effective and appropriate communication with physicians, with timely follow-up on all cases and resolution of those with clinical documentation clarifications.
  6. Participate in Task Force Meetings (Coder/CDI) and communicate with coders to resolve discrepancies.
  7. Perform accurate input data into the Track system.
Requirements
  • Graduation from a program of nursing, BSN preferred.
  • Current state Registered Nurse license.
  • Score (minimum of 70%) on the Clinical Competency Assessment (CCA).
  • 5 years of adult acute care experience in med/surg, critical care, emergency room, or PACU.
Core Competencies
  • Organizational, analytical, writing, and interpersonal skills.
  • Dependable, self-directed, and pleasant.
  • Critical thinking, problem-solving, and deductive reasoning skills.
  • Knowledge of Pathophysiology and Disease Process.
  • Basic Computer skills - familiarity with Windows-based software programs.
Work Environment

May be exposed to chemicals necessary to perform required tasks. Must be able to alternate between remaining stationary at the work station and walking to patient units. Constantly utilizes/operates computer to access information. Must be able to utilize multiple screens to view and document.

Flexible and able to adapt to changes. Primary population served: all populations, including bariatric patients with weight-related comorbidities.



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