Clinical Documentation Improvement Job Description
Clinical documentation improvement
provides feedback to CDI management team and staff regarding ICD 10 CM/PCS coding, DRG assignment and related clinical documentation issues or concerns.
Clinical Documentation Improvement Duties & Responsibilities
To write an effective clinical documentation improvement job description, begin by listing detailed duties, responsibilities and expectations. We have included clinical documentation improvement job description templates that you can modify and use.
Sample responsibilities for this position include:
Overseeing the coordination and evaluation of activities and workflow in Coding and Reimbursement, Chart Completion, Storage and Retention, Release of Information, Transcription Unit, and Systems Integrity areas
Ensuring the activities related to CDI
Overseeing the coordination of education to the medical staff regarding documentation improvement, DRG's, severity of illness and risk of mortality
Helping to ensure the improvement of coder's clinical knowledge and improving communication between providers and other members of the healthcare team
Hiring and orientation training, in-service and evaluations of personnel and institution regarding hospital organization, mission, management, policies and procedures
Overseeing Ongoing Medical Record Review activities and addressing compliance with Joint Commission Standards, CMS, NYSDOH, and hospital policies
Preparing the department's Operating, Salary and Capital budgets
Controlling and maintaining all expenditures in coordination with budget numbers
Selecting office equipment and overseeing all supplies ordered
Collaborating and fostering the concept of team building within an interdisciplinary clinical and administrative environment
Clinical Documentation Improvement Qualifications
Qualifications for a job description may include education, certification, and experience.
Licensing or Certifications for Clinical Documentation Improvement
List any licenses or certifications required by the position: CCDS, CDIP, CCS, RHIT, CCDIS, CDIS, RHIA, RN, ICD, BS
Education for Clinical Documentation Improvement
Typically a job would require a certain level of education.
Employers hiring for the clinical documentation improvement job most commonly would prefer for their future employee to have a relevant degree such as Associate and Bachelor's Degree in Nursing, Education, Associates, Health Information Management, Science, Medical, Health, Healthcare, Management, Graduate
Skills for Clinical Documentation Improvement
Desired skills for clinical documentation improvement include:
Medical terminology
Pharmacology
CDI strategies
Clinical documentation guidelines and CDI program implementation experience
Pathophysiology
Regulatory environment
Clinical documentation requirements that identify clinical conditions
Excel
Disease process and treatments
ICD-9-CM and CPT-4 codes
Desired experience for clinical documentation improvement includes:
CPUR, CPHM, CCM, or coding certifications (Preferred)
Utilizes the Performance Improvement Model
Utilizes excellent interpersonal skills to deal with challenging situations while maintaining strong supportive relationships
Demonstrates a proactive attitude and seeks to remedy situations before mistakes are made or corrects errors when found
Ensures accuracy of data collection and submission
Develops data reports for projects, committees, hospital departments, medical staff departments, as designated
Clinical Documentation Improvement Examples
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Clinical Documentation Improvement Job Description
Job Description Example
Our company is searching for experienced candidates for the position of clinical documentation improvement. Please review the list of responsibilities and qualifications. While this is our ideal list, we will consider candidates that do not necessarily have all of the qualifications, but have sufficient experience and talent.
Responsibilities for clinical documentation improvement
- Supports Precyse's Compliance Program by demonstrating adherence to all relevant compliance policies and procedures as evidenced by training participation and daily practice
- Drive improved accuracy with front line providers
- Defines the internal program offering and works with health plan resources to ensure appropriate workflow for deploying embedded staff at provider office settings for providers purchasing these enablement services
- Responsible for the operations, business, financial and human resource needs of the CDI department
- Be responsible for Client relations including providing performance and business updates to customer on a regular and on-going basis
- Plan daily operations of the department in conjunction with the Senior Director and participates in development of objectives to meet KPI’s
- Direct and maintains adequate staffing and workflow to meet CDI needs
- Monitor various reports and productivity to ensure that production standards and objectives are met in areas of responsibility
- Lead the CDI program as demonstrated by assuming accountability for the ongoing success of the Clinical Documentation Program
- Engage and consult with Physician Advisor when needed to resolve provider issues regarding answering clarifications and participation in the clinical documentation improvement process
Qualifications for clinical documentation improvement
- Exceptional organizational skills with the ability to prioritize multiple responsibilities simultaneously in a rapidly changing environment, meeting scheduled deadlines
- Demonstrated project management skills with the ability to drive multiple concurrent projects to completion in a complex, consensus-oriented environment
- Excellent written and verbal communication skills, including the ability to present ideas and concepts effectively to physicians, employees and leadership
- Excellent observation, communication, and decision making abilities
- Ability to work well with individuals from diverse levels and backgrounds
- Skills needed to assess, evaluate, and teach all members of the CDI and care team
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Clinical Documentation Improvement Job Description
Job Description Example
Our company is looking for a clinical documentation improvement. Please review the list of responsibilities and qualifications. While this is our ideal list, we will consider candidates that do not necessarily have all of the qualifications, but have sufficient experience and talent.
Responsibilities for clinical documentation improvement
- Develops and monitors strategic operating goals, objectives and budget
- Develops and manages direct reports
- Provide ongoing Clinical Documentation Improvement education for new staff and new initiatives or identified areas of knowledge deficit
- Design and implements education programs which provide education for CDIP staff
- Plan, organize, direct all activities related to Clinical Documentation Improvement program
- Directly supervise CDI staff, ensure that staff are functioning at a high level of productivity and quality, supporting the SBUH quality and CDI program goals and objectives
- Track and analyze CDI outcomes data and collaborate with Quality Management in planning and implementing actionable steps relative to the outcomes results, including identification and follow-up with coding opportunities clinical documentation opportunities
- Participate in the Strategy for Quality Management Initiative with the goal of improving metrics in various defined clinical divisions within SBUH, Function as Coding and Clinical Documentation lead in the Clinical Outcomes Group (COG)
- Develop and provide educational programs related to clinical documentation to physicians and other healthcare professionals responsible for patient health record documentation
- In collaboration with the Associate Director, Revenue Integrity Staff Development, identify, develop and provide ongoing education to coding staff and CDI staff related to the most current CDI and ICD-10-CM guidelines as related to CDI and coding initiatives
Qualifications for clinical documentation improvement
- Minimum of (5) five years recent inpatient coding experience with a strong understanding of Medicare's Inpatient DRG and other PPS methodologies
- Self-motivated with the ability to work under minimum supervision while understanding the importance of being part of a team
- May require extended periods of sitting, standing and walking
- Must be able to walk to attend meetings
- Identifies educational opportunities and coordinates division and facility based training programs
- 5 years of adult acute care nursing experience in med/surg, critical care, emergency room, or PACU preferred
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Clinical Documentation Improvement Job Description
Job Description Example
Our company is looking for a clinical documentation improvement. To join our growing team, please review the list of responsibilities and qualifications.
Responsibilities for clinical documentation improvement
- Collaborate with the Associate Director, Revenue Integrity to identify opportunities and deploy CDI resources to include Ambulatory Services
- Develop and maintain CDI program policies and procedures, consistent with current CMS and American Health Information Management Association (AHIMA) guidelines
- The individual will review data/metrics with providers at Medical staff meetings on individual physician basis
- Develops and manages the Clinical Documentation functions/activities at each of the currently 9 hospitals in West Florida Division
- Based upon strategic corporate initiatives and hospital goals develop Divisional Clinical Documentation work plan annually and report completed activities to CMOs, CNOs, CFOs and Quality leaders at each hospital
- Manages and oversees the daily operational Clinical Documentation hospital-based activities, data collection, analysis and reports
- Monitor and continuously manage productivity while reviewing and recommending staffing changes of Clinical Documentation teams at each hospital, based on the workload
- Annually review the Divisional Clinical Documentation program to ensure compliance to state and regulatory guidelines
- Identify Clinical Documentation improvement issues and foster excellent communication with physicians, nurses, coding and other members of the health care team to be able to work independently to resolve such issues
- Identify staff development opportunities, perform management and evaluation for all Clinical Documentation staff, perform timekeeping duties, responsible for screening and hiring of new employees
Qualifications for clinical documentation improvement
- Previous CDI experience is desirable, but not required
- Knowledge of ICD-10 is desirable
- Knowledge of Medicare Part A and Part B is preferred
- Able to manage multiple priorities and meet productivity targets
- Understand and support CDI documentation strategies (upon completion of training)
- Requires BA/BS in a clinical or health care field
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Clinical Documentation Improvement Job Description
Job Description Example
Our growing company is looking for a clinical documentation improvement. We appreciate you taking the time to review the list of qualifications and to apply for the position. If you don’t fill all of the qualifications, you may still be considered depending on your level of experience.
Responsibilities for clinical documentation improvement
- Broad knowledge of health care regulations
- Oversees that CDI staff are providing expert level review of inpatient clinical records within 24-48 hours of admit
- Proactively manages facility CDI and HSC MS-DRG discrepancy request reviews (including corresponding communications, escalation paths and tracking/trending/comparison of data)
- Reporting to HSC Leadership significant coding trends identified through the CDI process
- Maintains up-to-date knowledge of regulatory changes impacting coding requirements
- Coordinates training and education for coders and facility-based CDI staff when trends are identified
- Manages expectations and ensures services are delivered accordingly
- Initiate quality of care measure process for required conditions from the initial chart review process
- Initiate & participate in formal and informal, required and voluntary continuing education opportunities
- Be willing to learn and consistently take instructions from Superiors (Supervisor/Manager/Director ) whiles ensuring that the chain of command is followed within the department
Qualifications for clinical documentation improvement
- Minimum of five (5) years of progressive experience in an acute care hospital setting
- Registered Nurse with current D.C
- Minimum of 5 years recent clinical experience in an acute care setting
- BSN degree or equivalent
- Cardiology experience a plus
- Nurse (RN, NP), Physician (MD, DO, FMG), Physician Assistant (PA)
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Clinical Documentation Improvement Job Description
Job Description Example
Our innovative and growing company is hiring for a clinical documentation improvement. Please review the list of responsibilities and qualifications. While this is our ideal list, we will consider candidates that do not necessarily have all of the qualifications, but have sufficient experience and talent.
Responsibilities for clinical documentation improvement
- Coordinate the activities of the Documentation Improvement Committee
- Provide feedback to clinical documentation specialists, case managers, coders, physicians and other clinicians involved in the documentation improvement effort
- Work with finance department on continuous case mix modeling and assessment
- Participate in the rejections and claims review process with patient accounting to ensure both compliance and accurate reimbursement
- Direct coding activities to ensure accurate, consistent and compliant coding for all services
- Implement a documentation improvement program for outpatient services
- Trend and quantify the effectiveness of coding
- Organize process improvement/committee on a clinical or product line basis to address documentation improvement opportunities
- Develops and meets department budgets
- Provide strategic planning and direction for the development and enhancement of CDI program services through the National CDI Center of Excellence
Qualifications for clinical documentation improvement
- Minimum of 5+ years acute care hospital clinical RN experience or Foreign Medical Graduate with CDI experience
- CCDS or CDIP or CCS certifications
- Strong Analytical skills (with CDI metric related focus)
- Strong written and spoken communication abilities
- Strong ability to influence key stake holders
- Maintains up-to-date working knowledge of Medicare/Medicaid rules and regulations regarding CDI, basic coding, current trends and developments in the area of Clinical Documentation Improvement