Clinical Documentation Specialist-III Inpatient

WVU Medicine; United States; Remote; USD 90,000 - 125,000; Full time

Job summary

SYSTEM West Virginia University Health System is seeking a CDI leader to oversee the strategic management of service line integration across the system. The role emphasizes high-quality documentation and DRG accuracy to support hospital outcomes.

You will collaborate with CDI Educator/Manager on provider education, participate in revenue integrity meetings, and mentor junior CDI specialists while ensuring CMS guidelines are followed.

Qualifications

• CDI certification required from AHIMA/ACDIS/AAPC.
• Three years inpatient acute care coding OR three years RN/LPN in inpatient acute care.
• Five years of CDI experience.
• Excellent written and verbal communication skills.
• Knowledge of CMS, Medicare documentation, and coding regulations.
• Ability to mentor Level I/II CDI Specialists.

Responsibilities

• Assist CDI Manager in planning, executing, and delivering a high-quality CDI department.
• Assist in design, collection, and reporting of data for the System CDI Program.
• Collaborate with CDI Educator/Manager for provider education.
• Act as a CDI system service line expert for integration and strategic management.
• Attend revenue integrity meetings for the designated system service line.
• Perform concurrent reviews and DRG/ APR-DRG assignments.
• Identify documentation gaps and pursue queries with physicians and staff.
• Provide education on documentation issues and CMS guidelines.
• Promote compliance with CMS and coding regulations; report improvements.
• Mentor and advise CDI staff (Level I and II).

Skills

Communication skills

Analytical skills

Time management

Independence

Concentration

Education

CDIP (AHIMA)

CCDS (ACDIS)

CDEI (AAPC)

Tools

Microsoft Office

Job description

Welcome! We’re excited you’re considering an opportunity with us! Below, you’ll find other important information about this position.

Responsible for strategic management of service line integration throughout the system. Capable of focused and second level reviews. Performs independently at the highest level of expectation. Assists Manager on specific projects as assigned.

MINIMUM QUALIFICATIONS** :**

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

1. Certification in ONE of the Following:

• Certified Documentation Integrity Practitioner (CDIP) through the American Health Information Management Association(AHIMA)

• Certified Clinical Documentation Specialist (CCDS) through the AssociationofClinicalDocumentationIntegritySpecialists(ACDIS)

• Certified Documentation Expert Inpatient (CDEI) through the American Association of Professional Coders (AAPC)

EXPERIENCE:

1. Three (3) years Inpatient acute care coding experience OR

Three (3) years clinical RN experience in Inpatient acute care setting OR

Three (3) of clinical LPN experience in Inpatient acute care setting.

1. Five (5) years of experience in Clinical Documentation Integrity.

CORE DUTIES AND RESPONSIBILITIES: The statements described here are intended to describe the general nature of work being performed by people assigned to this position. They are not intended to be constructed as an all-inclusive list of all responsibilities and duties. Other duties may be assigned.

1. Assists CDI Manager in the planning, execution, and delivery of ahigh-qualityCDI department.

2. Assists CDI Manager in the design, collection, and reporting of relevant data to support the System CDI Program.

3. Collaborates with CDI Educator/Manager for provider educational opportunities.

4. As a CDI system service line expert, responsible for integration and strategic management of service line, keeping the service line team focused on CDI greatest impact.

5. Attends all revenue integrity meetings related to their designated system service line.

6. Capable of efficient review and timely results for focused DRGs and second level reviews.

7. In collaboration with the providers and staff, identifies and recordsprinciplediagnoses, secondary diagnoses, procedures, and assigns a working Diagnostic Related Group (DRG).

8. Conducts initial concurrent review and ongoing re-reviews for all selected admissions by documenting findings regarding DRGs, APR-DRGs and Value Based Purchasing/Quality measures.

9. Identifies need to clarify documentation through quality audits in records and initiates communication with physician, nurse, or patient care coordinator by utilizing the appropriate query tools in order to capture the documentation in the medical record that accurately supports the patient’s severity of illness.

10. Provides information and ongoing education as necessary to providers and staff on documentation issues, guidelines, and unanswered queries

11. Promotes compliance with CMS, Medicare documentation, and coding and billing regulations.

12. Participates in the processes to assess and improve the services provided and compliance with regulatory requirements. Report results assessment and improvement processes to the appropriate administrative levels.

13. Collaborate with the Quality Department to ensure documentation meets quality initiative standards used for measuring and reporting hospital and provider outcomes.

14. Collects,analyzesand submits timely, accurate and complete reports of clinical documentation information used for measuring and reporting Hospital and Provider outcomes data.

15. Works with the Coding Specialists on any issues that arise concerning documentation, providers, and queries to enhance the concurrent process to enable prompt coding.

16. Serves as a mentor and advises Level I and II CDI Specialists.

PHYSICAL REQUIREMENTS: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. Must be able to sit for long periods of time.

2. Must have visual and hearing acuity within the normal range.

3. Must have manual dexterity needed to operate computer and office equipment.

WORKING ENVIRONMENT: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. Standard office environment.

2. May be exposed to standard patient care environment.

3. Visual strain may be encountered in viewing computer screens, spreadsheets, and other written material.

4. May require travel.

SKILLS AND ABILITIES:

1. Must possess excellent written and verbal communication skills, as well as interpersonal skills necessary to communicate effectively.

2. Must possess the knowledge of related provider healthcare compliance, revenue cycle operations, and auditing techniques required.

3. Must possess the ability to accept mentoring,educationand training from others.

4. Must meet quality and productivity standards.

5. Must be able to concentrate and maintain accuracy during constant interruptions.

6. Must possess the ability to prioritize job duties.

7. Must be able to adapt to changes in the workplace and work assignments.

8. Must possess organizational and time management skills.

9. Must possess the knowledge of anatomy,physiologyand medical terminology.

10. Must possess analytical andproblem-solvingskills.

11. Must be proficient in office software programs.

12. Must be able to work independently with minimal supervision.

Additional Job Description:

Remote

Scheduled Weekly Hours:

40

Shift:

Exempt/Non-Exempt:

United States of America (Exempt)

Company:

SYSTEM West Virginia University Health System

Cost Center:

538 SYSTEM HIM CDI