Clinical Documentation Specialist
1 week ago
Job Relationships
- Department: Health Information Management
- Supervisor: HIM Manager
- Supervises: None
Job Summary
The Clinical Documentation Improvement (CDI) Specialist is responsible for enhancing the quality and accuracy of clinical documentation within the healthcare facility. This role involves working closely with healthcare providers to ensure that clinical records accurately reflect patient diagnoses, procedures, and care provided, in accordance with regulatory guidelines. The CDI Specialist will review medical records, identify discrepancies, and collaborate with physicians and other healthcare staff to clarify and improve documentation. By ensuring thorough and accurate documentation, the CDI Specialist supports improved patient outcomes, compliance with coding and billing regulations, and optimal reimbursement.
Compensation
We are committed to providing wage ranges for all open positions. Please note that the specific compensation for this role will be determined based on experience, education and internal equity considerations. The hourly wage range for this position is $ $51.02. This range reflects the base salary for this position.
Key Accountabilities
- Perform expert level review of inpatient and observation clinical records within 48 hours of admission, as well as on a daily basis, concurrent with patient stay.
- Identify principal and secondary diagnoses in order to accurately reflect the patient's hospital course utilizing ICD-10-CM with appropriate application of coding conventions and guidelines.
- Ensure accuracy of MS-DRG grouping and APC assignments.
- Collaborate with inpatient and observation providers to ensure documentation accurately reflects severity of illness and acuity of care being provided, as well as identify opportunities for clarification of documentation.
- Perform expert level review of outpatient clinic records and communicate with providers any opportunities for improvement of clinical documentation to support medical necessity of care rendered.
- Communicate with providers at all levels by effectively articulating queries and rationale for queries/requests for clarification. Provide follow through on all queries and requests for clarification.
- Provide education to healthcare providers to reinforce best practices in clinical documentation, leading to more accurate and complete medical records.
- Collaborate with coding staff to review problematic cases and ensure accurate and appropriate code assignment.
- Review and analyze data to identify trends, variance, and opportunities to improve documentation as well as improvement of documentation review processes. Report findings to HIM Manager.
- Actively participate in interdisciplinary committees to support documentation improvement efforts across the facility. Monitor changes in laws, regulations, and policies affecting clinical documentation to ensure ongoing compliance and best practices.
Required Qualifications
- RN with 3-5 years of acute care experience OR
- RHIT/RHIA with 3-5 years of inpatient coding experience
- Must be able to speak, read, and write English proficiently to ensure safe and effective communication in a healthcare environment
Preferred Qualifications
- CDIP (Certified Documentation Improvement Practitioner) or CCDS (Certified Clinical Documentation Specialist) Credential, RHIA (Registered Health Information Administrator), RN (Registered Nurse), CCS (Certified Coding Specialist)
- Basic knowledge of ICD-10 coding and DRG's
Schedule
- 80 hrs per 2 week pay period
- Monday-Friday, 8:00am-4:30pm
- This position follows a hybrid schedule and requires working on-site at least 3 days per week.
Benefits
- Paid Time Off accrued on first paycheck
- Medical and Dental Insurance, Vision Discount Plan
- Flexible spending accounts
- Life, accidental death & dismemberment, disability insurance
- Pension Plan (PERA) with a 7.5% company match
- 457(b) retirement plans available
- Tuition Reimbursement
- On-site Continuing Education
- Free on-site parking
- Other benefits include our Qualified Bilingual Staff Program, Employee Assistance Program, and a variety of savings opportunities, including cafeteria, scrubs, and OTC medication discount from our pharmacy.
Northfield Hospital + Clinics is an independent organization with over 800 employees. We are known for our positive work environment and quality patient care. We provide a full spectrum of services with our Hospital in Northfield, MN and primary and specialty clinics in Northfield, Lakeville, Farmington, Faribault, and Kenyon, plus Urgent Care locations in Northfield and Lakeville.
Location: Northfield Hospital & Clinics · Clinical Documentation Information
Schedule: Full Time , Day, 80 hrs/2 wks
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