Clinical Documentation Specialist

Hennepin Healthcare; Minneapolis (MN); Remote; USD 90,000 - 120,000; Full time

Job summary

Hennepin Healthcare seeks a Clinical Documentation Improvement (CDI) professional to perform concurrent reviews of inpatient admissions and enhance documentation quality. You will work with physicians and care teams to ensure DRG accuracy, illness severity, and risk of mortality are properly reflected in documentation and coding systems.

The role emphasizes physician education, timely queries, and ongoing CDI program support to optimize reimbursement and patient care outcomes.

Qualifications

• Graduation from an accredited school of nursing.
• RHIA or RHIT with inpatient coding experience.
• RN license maintained with state nursing board (Minnesota).

Responsibilities

• Perform initial and continued-stay concurrent reviews of inpatient admissions using CDI and Epic systems.
• Identify procedures and diagnoses for comorbidities and DRG assignments.
• Query providers to obtain complete and accurate documentation.
• Ensure timely documentation before patient discharge when possible.
• Educate physicians and clinicians on documentation best practices.
• Apply ICD-10-CM/PCS guidelines to ensure compliance.

Skills

Interpersonal skills

Communication skills

Computer skills

Medical terminology

Time management

Organizational skills

Dental knowledge

Insurance knowledge

Customer service

Independence

Education

Registered Nurse (RN) license

RHIA certification

RHIT certification

Tools

Epic EHR

Job description

JOB DETAILS Department: Clinical Documentation Improvement FTE: 1.00 (80 hours per pay period) Workdays: Monday - Friday Shift(s): Days Shift Length: 8 hours Location: Remote* *Current List of non-MN States where Hennepin Healthcare is an Eligible Employer: Alabama, Arizona, Arkansas, Delaware, Florida, Georgia, Idaho, Illinois, Indiana, Iowa, Kansas, Louisiana, Mississippi, Nevada, North Carolina, North Dakota, New Mexico, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Wisconsin.

Purpose of this position: Under the direction of Coding and Documentation leadership, provides active concurrent review, feedback, and education to physicians and healthcare providers to improve documentation of all conditions and treatments in the inpatient medical record, to ensure an accurate reflection of the patient condition in the associated MS-DRG assignments, case-mix index, severity of illness and risk of mortality profiling and reimbursement.

RESPONSIBILITIES

• Conducts initial and continued-stay concurrent reviews on inpatient admissions and documents findings using the designated CDI software, Coding software and Epic electronic record as necessary/ requires proficiency in abstracting the needed clinical information and data used for clinical documentation
• Identifies procedures and secondary diagnoses for co-morbidities/complications and documents appropriately within the designated CDI software, Coding software and Epic electronic record as needed to accurately calculate the correct DRG assignment
• Identifies documentation issues within the medical record around ICD-10-CM Diagnosis and ICD-10 PCS procedure codes
• Communicates via a query process to the Medical Staff, Advanced practice practitioners (APP's) and other providers, including medical residents as necessary, via written/verbal communication to obtain accurate and complete provider documentation
• Assigns baseline and working DRG (APR or MS DRG), along with Severity of illness and Risk of Mortality to reviews using ICD-10-CM /PSC codes and procedures to all reviews
• Ensures the timeliness of all written and verbal queries from providers to ensure proper documentation is obtained and placed in the medical record before patient discharge whenever possible
• Identifies potential Patient safety indictors (PSI) and Hospital acquired conditions (HAC) codes and notifies appropriate staff personnel for further review
• Conducts post discharge reviews and reconciliation of DRG assignment and baseline DRG, ensuring correct outcome for all coding queries responses
• Educates physicians, clinicians, and other involved parties regarding the necessity of providing complete and clear documentation of the care provided. This may require the use of computer software and developing education using software such as PowerPoint
• Applies federal and state documentation and coding (ICD-10-CM/PCS) guidelines to ensure physician and hospital compliance. Maintains current knowledge of coding/documentation information including the AHAs Coding Clinic publication, pharmacology, laboratory, disease processes, and new/emerging technologies to ensure accuracy of code assignment and compliance
• Identifies documentation trends and issues and reports these to CDI leadership, as well as the inpatient coding management and staff as needed
• Interacts with coding team to resolve documentation and coding issues and ensure proper DRG assignment
• Be able to prepare and provide service-specific information and education to physicians and other care providers, related to provider documentation and its effects on coding, compliance, profiling and reimbursement
• Participates in educational programs and in-services in order to maintain clinical documentation requirements, knowledge and ICD-10-CM /PCS coding requirements
• Portrays a professional manner in dress and all communication skills
• Must have effective interpersonal skills to effectively interact, communicate, and maintain good working relationships with Medical Staff, Advanced Practice Practitioners (APP's), other provers and team members
• Must be able to work with minimal supervision and assist others in completing the work of the team.
• 18. Performs other tasks as assigned

QUALIFICATIONS

• Graduation from an accredited school of nursing, and two (2) years of professional nursing experience in an emergency department, medical or surgical area of an acute hospital setting
• Graduation from an AHIMA accredited program as a Registered Health Information Administrator (RHIA) and at least three (3) years of recent inpatient coding experience
• Graduation from an AHIMA accredited program as a Registered Health Information Technician (RHIT) and at least four (4) years of recent inpatient coding experience
• An approved equivalent combination of education and experience

CERTIFICATION / LICENSE REQUIRED

• Registration as a Registered Health Information Administrator (RHIA) or Registered Health Information Technician (RHIT) by the American Health Information Management Association.
• Maintain current licensure by the Minnesota Board of Nursing as a Registered Nurse (RN)

PREFFERED QUALIFICATIONS

Bachelor's degree with some dental focus and business background

KNOWLEDGE / SKILLS / ABILITIES

• Knowledge of specialty healthcare and dentistry
• Knowledge of dental insurance and financial coordination
• Excellent communication skills in person and on telephone
• Excellent customer service skills
• Knowledge of medical terminology
• Advanced computer skills
• Ability to work effectively with others
• Ability to work independently and efficiently
• Exceptional time management skills
• Ability to adapt to changing priorities and regulations
• Essential knowledge of dental insurance coverages and programs,including prior authorization, payment plans, and collecting co-pays or payments
• Strong organizational skills