Clinical Documentation Improvement Specialist

South Shore Health System; South Weymouth (MA); On-site; USD 90,000 - 120,000; Full time

Job summary

South Shore Health System seeks a Clinical Documentation Improvement Specialist to develop and maintain documentation accuracy across inpatient and observation cases. The role involves on-site collaboration with physicians and HIM staff to ensure documentation supports illness severity and appropriate reimbursement.

The ideal candidate will hold an RN license in Massachusetts, have 5 years of nursing experience with coding education, and preferably CCS certification.

Qualifications

• Graduate from an accredited school of nursing with a license to practice professional nursing in Massachusetts.
• Five (5) years nursing experience with coding education; Clinical Documentation Improvement (CDI) experience preferred.
• RN license required; CCS certification preferred.

Responsibilities

• Perform concurrent review to ensure documentation reflects severity of illness and assigns working DRG.
• Educate physicians and staff on documentation best practices and DAP concepts.
• Collaborate with Health Information Management and CDI team to improve program effectiveness.
• Review data to identify trends and develop action plans.

Skills

Nursing experience

CDI experience

Coding education

Communication skills

Leadership

Education

RN license

BSN preferred

CCS certification preferred

Job description

Job Description Summary

Under the general supervision of the Manager of Clinical Documentation, will assist to develop, implement, and maintain the documentation accuracy initiative at the Hospital. This position is responsible for the concurrent review of the clinical documentation in the medical record and concurrent querying of medical staff caregivers to obtain accurate and complete documentation, which appropriately supports the severity of patient illness. The documentation specialist is on–site and available five (5) days a week.

Job Description

ESSENTIAL FUNCTIONS

1. Performs concurrent review process for all selected admissions to ensure documentation accurately reflects the severity of patient’s illness

• a. Produce worklists from Epic daily to review case on day 2 as well as daily throughout the patient’s stay. Patients admitted and discharged on the weekend will be reviewed in coding before the bill is dropped. Review all inpatient cases and observation or surgical day cases that has the potential to be converted to an inpatient admission
• b. Identifies and records principle and secondary diagnoses, principle procedures, and assigns a working DRG on Documentation worksheet.
• c. Identifies need to clarify documentation in records and initiates assertive communication with physician or other care provider by using the most appropriate communication method for that individual – physician documentation request, face to face contact, phone call, etc.
• d. Inputs current DRG into Epic for all Medicare patients daily.
• e. Inputs and reconciles queries on excel datasheet daily.

2. Provide information and education as necessary to physicians and other care providers specific to DAP.

• a. Present overview of program to new physicians and other care providers at orientation
• b. Follow up with new physicians who document in medical records in a one-to-one meeting
• c. Provide ongoing information/education as necessary to physicians and other care providers not responding to documentation requests
• d. Assist in providing feedback to medical staff regarding performance as it relates to accuracy of opportunities to improve documentation.
• e. Continual medical staff education as a proactive measure.

3. Maintains a collaborative working relationship with team and with the Health Information Management department staff.

• a. Perform focused reviews, both concurrently and retrospectively, to determine areas where information and/or education may be required for the team or members of the team to improve program effectiveness
• b. Perform focused reviews, both concurrently and retrospectively, to determine areas where information and/or education may be required for physicians or other care providers to improve program effectiveness
• c. Share pertinent coding and DRG reference materials (e.g. coding clinics)
• d. Share pertinent clinical information (e.g. new drugs/treatments)
• e. Identification of improvements needed by physicians with continued documentation needs to medical staff liaison for further action

4. Reviews, evaluates, analyzes and interprets data related to documentation from internal sources and external sources on an on-going basis

• a. Identifies trends or potential problems and assists in developing action plans to address.

5. Track and provide regular (monthly, other) report for mortality, queries, and case mix in support of hospital wide initiatives.

6. Participates in organizational surveys that evaluate staff perception of safety.

7. Seeks and participates in educational opportunities to improve job skills and program.

8. Demonstrates knowledge of organizational safety priorities and their department specific application, methods of reporting safety concerns and opportunities.

9. Identifies annually at least one implementable idea to improve patient, staff or environmental safety.

10. Successfully answers safety questions in annual mandatory education program.

11. Understands roles/responsibilities during hospital codes.

12. Adheres to respiratory etiquette guidelines.

JOB REQUIREMENTS

Minimum Education

Graduate from an accredited school of nursing with a license to practice professional nursing in Massachusetts
BSN preferred

Minimum Work Experience

Five (5) years nursing experience with coding education
Clinical Documentation Improvement (CDI) experience preferred.

Required License

RN - Registered Nurse

Preferred Certification

CCS - Certified Coding Specialist

Required additional Knowledge, and Abilities

Excellent communication and critical thinking skills.
Demonstrates leadership qualities such as the ability to motivate, teach, and facilitate individuals and groups on reaching the objectives of the program.
Working knowledge of Medicare and Blue Cross inpatient reimbursement and coding structures is desired.
Knowledge of care delivery documentation systems and related medical record documents desired.
Knowledge of age-specific needs and the elements of disease processes and related procedures preferred.
Self-motivated, innovative individual who has the ability to work in a time-oriented environment.
Prefer experience interacting with physicians and concurrent review with clinical records.
Basic personal computer skills required.