Clinical Documentation Integrity Specialist

Children's Hospital of The King's Daughters; Norfolk (VA); On-site; USD 90,000 - 110,000; Full time

Job summary

The Clinical Documentation Integrity Specialist at Children's Hospital of The King's Daughters reviews inpatient medical records to ensure accurate diagnosis and procedures, supporting compliant documentation and proper reimbursement. This RN role reports to department leadership and collaborates with physicians and HIM staff.

Required Virginia RN license; BSN preferred; certification such as CDIP/CCDS preferred within two years.

Qualifications

• Current Virginia state license as a Registered Nurse required.
• BSN preferred.
• Experience applying clinical criteria to medical record reviews.
• Knowledge of MS-DRG, Tricare, and APR-DRG reimbursement systems.
• Strong organizational, analytical, and communication skills.

Responsibilities

• Review inpatient clinical documentation to ensure accurate reflection of diagnoses, treatments, and procedures for proper reimbursement.
• Educate physicians and ancillary providers on accurate, compliant documentation.
• Serve as a resource for departments on clinical documentation integrity and regulations.
• Perform additional duties as assigned.

Skills

Clinical Documentation Integrity

RN license

MS-DRG knowledge

Education/communication

Education

Registered Nurse license (Virginia)

BSN preferred

Tools

Microsoft Office Suite

Electronic Medical Records

Job description

The Clinical Documentation Integrity Specialist is responsible for reviewing inpatient medical records to assess and procure accurate and complete documentation of the patients’ diagnosis and procedures. Reports to department leadership.

ESSENTIAL DUTIES AND RESPONSIBILITIES

• Reviews Inpatient Clinical Documentation, ensuring that physicians’ and clinicians’ documentation, accurately reflect the patient’s conditions, diagnoses, treatments, and interventions, resulting in accurate reimbursement.
• Reviews to ensure the clinical documentation, reflects the patient’s severity of illness, quality of care and resources used.
• Provides education to the physicians and ancillary providers regarding accurate, specific and compliant clinical documentation.
• Acts as a resource for other departments regarding the importance of clinical documentation integrity, and the need to clinically document following the Federal and State regulations.
• Performs all other duties as assigned.

LICENSES AND/OR CERTIFICATIONS

• Required Licenses and/or Certifications
• Current Virginia state license as a Registered Nurse or Registered Nurse holding a valid Compact State license required.
• Preferred Licenses and/or Certifications
• Certified Documentation Improvement Professional (CDIP) or Certified Clinical Documentation Specialist (CCDS) certification or must be credentialed through AHIMA or ACDIS, within two years of start preferred.

MINIMUM EDUCATION AND EXPERIENCE REQUIREMENTS

• Required Education and Experience
• Registered Nurse -Professional knowledge of nursing theory and practice at a level normally acquired through the completion of an accredited School of Nursing.
• Preferred Education and Experience
• BSN preferred.
• Pediatric and or Clinical Documentation or Utilization Management preferred.
• Required Knowledge, Skills and Abilities
• Experience with applying clinical criteria to a medical record review with a Clinical Documentation Integrity focus.
• Knowledge of healthcare payment systems, specifically the MS-DRG, Tricare and APR-DRG reimbursement systems.
• Ability to form positive and collaborative relationships, with Physicians, HIM colleagues, the Physician Advisor and other hospital staff.
• Competent using Microsoft Office Suite, and different Electronic Medical Records.
• Requires Strong organizational, clinical critical thinking and analytical skills.
• Preferred Knowledge, Skills and Abilities
• Technical and professional knowledge and skills for clinical operations of the service area, usually acquired through 3 - 5 years’ progressive Clinical/Supervisory experience in a practice setting.

WORKING CONDITIONS

• Normal office environment with little exposure to excessive noise, dust, temperature and the like.

PHYSICAL REQUIREMENTS

• Click here to view physical requirements.