Clinical Documentation Specialist

EDUCATION, EXPERIENCE AND TRAINING: Current Indiana License as a Registered Nurse required. BSN required. At least three (3) years of recent acute care nursing experience required. ICU experience preferred. Clinical Documentation Specialist and Coding Specialist certifications through appropriate professional organization(s) required within 12 months of hire into position. Membership in Indiana ACDIS Chapter is required within 30 days of hire into position.

JOB RESPONSIBILITIES: Reviews inpatient medical records to identify the most appropriate principal diagnosis and to assign a working Diagnosis Related Group (DRG). Performs initial reviews, concurrent reviews, and retrospective reviews to ensure the DRG accurately reflects the principal diagnosis and all comorbid conditions after study.

1. Completes the initial review within 24-48 hours of admission.

2. Completes concurrent reviews to ensure working DRG and all comorbid conditions are documented by the providers to the greatest specificity.

Confers with HIM coding staff concurrently to ensure appropriate MS-DRG assignment and completeness of documentation.

Monitors and triages Clinical Documentation Integrity (CDI) review opportunities for identified cluster DRG's to ensure the documentation is complete and accurate.

Creates, manages, and monitors CDI dashboard and reports performance to stakeholder meetings, including the organizational Utilization Review Committee meeting.

Utilizes a compliant query process per guidelines and policy when conducting all queries. Follows each query through to closure including complete documentation of ongoing follow up activities and communication. Updates compliant query templates. Serves as a resource for physician/provider queries to ensure efficient query response.

Explores CDI process creation and efficiency in new areas (outpatient CDI including the Emergency Department, same day stays, observation cases, clinic, denials, medical necessity, etc.) as well as opportunities outside of the ICD-10-CM/PCS code set.

Supports and implements performance improvement and quality measures as identified by department manager.

Creates educational content and educates internal staff on clinical documentation and coding guidelines, based on continual needs assessments. Develops and conducts ongoing education for new staff including new coders, physicians/providers, residents, nursing staff, and allied health professionals. May provide one-on-one training to providers as needed.

Functions as a subject matter expert and problem-solver regarding CDI.  Assists in other monitoring activities, special department projects, or other needs as determined by the department manager.

Maintains integrity and compliance in all chart reviews, documentation, and queries at all times.

Works collaboratively with Physician Advisor to ensure positive program outcomes.

Develops and supports strong professional relationships with coding staff, Physician Advisor, and medical providers across the system.

 Performs other related duties as assigned.

Clearly communicates and continuously supports the Mission and Values of Johnson Memorial Health.

Conducts all activities in compliance with applicable laws, regulations, standards, and Johnson Memorial Health policies and procedures including Blood and Body Substance Precautions and JMH's Equal Opportunity and Affirmative Action Policy.

Johnson Memorial Health is a nationally-recognized network of physicians, services and healthcare resources based in Johnson County, Indiana. The centerpiece is Johnson Memorial Hospital, located in Franklin Indiana, just 20 minutes south of Indianapolis.

All qualified applicants will receive consideration for employment without regard to race, age, sex, color, religion, sexual orientation, gender identity, national origin, protected veteran status, disability, or other protected characteristic under applicable law.

SCHEDULE: