Clinical Document Improvement Specialist- 40/hrs, Day Shifts

Temple-Health; Huntingdon Valley (PA); On-site; USD 65,000 - 90,000; Full time

Job summary

Temple Health is seeking a Clinical Document Improvement Specialist to lead medical record documentation improvements and support accurate DRG, SOI, ROM, and quality metric reporting. The role requires interpretation of ICD-10 coding and education across the treatment team.

The candidate should have a healthcare-related degree and relevant experience, with potential for combination of education and experience in lieu of a degree.

Qualifications

• Bachelor's Degree in a related field or an Associate's degree in a healthcare related field.
• with 5 years of related experience Required or
• Combination of relevant education and experience may be considered in lieu of degree Required

Responsibilities

• Serves as the primary resource to the treatment team on all aspects of medical record documentation required to support the accurate classification of patient's severity of illness/medical complexity.
• Clarifies documentation regarding quality of care issues and educates staff on ICD-10 implementation.

Skills

Clinical documentation

ICD-10

DRG coding

SOI

ROM

Education

Bachelor's or Associate degree in healthcare

Tools

ICD-10 system

Job description

Clinical Document Improvement Specialist- 40/hrs, Day Shifts

Tracking Code

264828

Weekly Hours

40.00

Schedule

Full-Time

Shift

Day Shift

Serves as the primary resource to the treatment team on all aspects of medical record documentation required to support the accurate classification of patient's severity of illness/medical complexity. Possess extensive knowledge of both clinical medicine and disease management, as well as the internal and external patient classification systems that measure patient's severity of illness and medical complexity. Additionally, the CDI specialist will be the primary educator for the implementation of the International Classification of Disease Classification System, 10th revision. The CDI specialist shall be responsible for clarifying documentation regarding quality of care issues. Responsible for the daily review of current inpatient medical records, abstracts pertinent clinical information and translates the clinical information into a hospital based coding system utilizing ICD-10. Identifies opportunities for documentation improvement to support accurate assignment of diagnostic related groups (DRGs), severity of illness (SOI) assignment, risk of mortality (ROM) assignment, and correct reporting of quality metrics. Communicates with the clinical staff through a variety of means to educate the staff and obtain clarification of documentation.

Education

• Bachelor's Degree in a related field or an Associate's degree in a healthcare related field
• with 5 years of related experience Required or
• Combination of relevant education and experience may be considered in lieu of degree Required

Experience

• 2 years experience in Patient care or Coding (inpatient medical setting) Required
• 5 years experience in inpatient acute care Preferred

Licenses

• Certified Coding Specialist Preferred or
• PA Practical Nurse License Preferred or
• PA Registered Nurse License Preferred
• Multi State Compact RN License Preferred Or