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Clinical Documentation Specialist III
3 months ago
POSITION SUMMARY
:(Briefly describe the overall purpose of this position - Why does it exist and how does it contribute to the overall organization?)
The Clinical Documentation Integrity Specialist (CDIS) provides clinically based, concurrent and retrospective reviews of
inpatient medical records. CDI strives to ensure accurate, complete, compliant, concise, and consistent documentation that reflects the true clinical scenario of the patient’s encounter. This additionally serves to reflect the true Severity of Illness (SOI), Risk of Mortality (ROM), and Intensity of Services (IOS) rendered to provide quality care and treatment to the patient. The Clinical Documentation Integrity Specialist serves as a liaison between leadership, medical staff, nursing, coding, case management and quality departments. Excellent communication skills and the ability to critically analyze are essential to successful CDI performance. The CDIS III is an advanced level position for experienced and proficient CDI
Specialists consistently meeting or exceeding all criteria for CDIS II performance.
KEY RESPONSIBILITIES:
(Use bullets for specific responsibilities)
REQUIRED KNOWLEDGE & SKILLS:
(Examples: Ability to work independently and take initiative; Good judgment and problem-solving skills; Communication skills; Interpersonal and organizational skills; Level of confidentiality)
• Must possess strong organizational, communication and clinical foundation skills.
• Must demonstrate proficiency in EMR software, CDI applications (after education and orientation) and Microsoft applications.
• Demonstrates ability to multi-task and work efficiently and effectively between software platforms.
• Demonstrates the ability to communicate effectively in a fast-paced environment with multidisciplinary teams consisting of physicians, nurses, coders, administration, and other health care professionals.
• Demonstrates proficiency in CDI process after completion of onboarding and orientation/education. Continued improvement in proficiency and accuracy is expected during and after orientation/onboarding.
• Experienced CDI Specialists are expected to onboard more quickly and meet perform commensurate with experience level.
• Ability to work independently, prioritize tasks and demonstrate self-awareness in the workplace.
• Always maintain confidentiality and HIPAA compliance.
EDUCATION/EXPERIENCE/LICENSURE/TECHNICAL/OTHER:
I. Education: Bachelor’s degree in a clinical or coding study is preferred. Advanced degrees such as Master, Doctorate or Foreign Medical Graduate will require proof of degree status.
II. Experience: Minimum of 2-5 years acute clinical or coding (IP) experience preferred. A minimum of 2 or more years CDI experience required with proficiency consistently demonstrated.
III. Licensure/Certification: RN or LVN with current state license. CCDS or CDIP certification is required with proof of current, active certification.
IV. Software/Hardware: Proficiency in Microsoft applications, EMR applications, CDI, and coding software
About Steward Health Care
Over a decade ago, Steward Health Care System emerged as a different kind of health care company designed to usher in a new era of wellness. One that provides our patients better, more proactive care at a sustainable cost, our providers unrivaled coordination of care, and our communities greater prosperity and stability.
As the country's largest physician-led, minority-owned, integrated health care system, our doctors can be certain that we share their interests and those of their patients. Together we are on a mission to revolutionize the way health care is delivered - creating healthier lives, thriving communities and a better world.
Based in Dallas, Steward currently operates more than 30 hospitals across Arizona, Arkansas, Florida, Louisiana, Massachusetts, Ohio, Pennsylvania, and Texas.
