Clinical Documentation Improvement Specialist Job Description
Clinical documentation improvement specialist
provides feedback to the CDI management team and staff regarding ICD-9-CM or ICD 10 CM/PCS coding, DRG assignment and related clinical documentation issues or concerns.
Clinical Documentation Improvement Specialist Duties & Responsibilities
To write an effective clinical documentation improvement specialist job description, begin by listing detailed duties, responsibilities and expectations. We have included clinical documentation improvement specialist job description templates that you can modify and use.
Sample responsibilities for this position include:
Possesses in-depth knowledge of MSDRG payer issues, documentation opportunities, clinical documentation requirements, and referral policies and procedures
Ensures all clinical documents are in compliance with federal laws in terms of composition and secure storage
Applies knowledge of medical terminology and medical procedures to properly evaluate clinical documents
Works collaboratively with the healthcare team to facilitate documentation within the medical record that supports patient’s severity of illness and risk of mortality
Assists in screening process, makes referrals, collaborates with Case Managers, ARNP’s, Physicians, and clinical nurse specialists to ensure continuity of patient care and validates clinical documentation with the plan of care
Reviews clinical issues with coding staff as needed to ensure appropriate MSDRG
Serves as Facilitator of the Clinical Documentation Improvement work group, Assists with special projects as needed & performs other duties as assigned
Conducts initial and extended-stay concurrent reviews on all selected admissions for opportunities to clarify documentation in the medical record for accurate reflection of severity of illness, and documents findings, denoting all key information utilized in the tracking process
Identifies need to clarify documentation in records, and utilizes strong communication skills with physician, physician extender, case manager, nurse or other healthcare professionals, utilizing appropriate query tools to capture needed documentation
Ensures the accuracy and completeness of clinical information used for measuring and reporting physician and hospital outcomes, including POA – Present on Admission conditions and Core Measures
Clinical Documentation Improvement Specialist Qualifications
Qualifications for a job description may include education, certification, and experience.
Licensing or Certifications for Clinical Documentation Improvement Specialist
List any licenses or certifications required by the position: CCDS, CCS, RHIT, CDIP, CDIS, CCDIS, RHIA, RN, ICD, CPC
Education for Clinical Documentation Improvement Specialist
Typically a job would require a certain level of education.
Employers hiring for the clinical documentation improvement specialist 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, Department of Education, Health, Medical, Anatomy, Graduate, Physiology
Skills for Clinical Documentation Improvement Specialist
Desired skills for clinical documentation improvement specialist include:
Medical terminology
Clinical documentation guidelines and CDI program implementation experience
Pharmacology
CDI strategies
ICD-9-CM and CPT-4 codes
Federal
Coding principles and guidelines
Clinical documentation requirements
DRG payor issues
Pathology
Desired experience for clinical documentation improvement specialist includes:
Educates all internal customers on clinical documentation opportunities, coding and reimbursement issues, performance improvement methodologies
Reviews the progress of the concurrent documentation review program, through interpretation of process and operational reports, financial and compliance reports, and quality ratings reports
Tracks response to Clinical Documentation and trends together with Coding/Medical Records
Ability to stand and walk in the performance of job responsibilities
Minimum of five (5) years recent clinical experience in an acute care setting, or a combination of clinical experience and MSDRG/ICD-9 coding experience
Utilization review or coding experience preferred (Preferred)
Clinical Documentation Improvement Specialist Examples
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Clinical Documentation Improvement Specialist Job Description
Job Description Example
Our innovative and growing company is looking to fill the role of clinical documentation improvement specialist. Thank you in advance for taking a look at the list of responsibilities and qualifications. We look forward to reviewing your resume.
Responsibilities for clinical documentation improvement specialist
- Works cooperatively with physicians and other providers to assure integrity of clinical documentation
- Utilizes CDI software and documentation of work product is consistent with goals of the department and AHS
- Documentation of CDI efforts are clear, concise, and complete
- RN Clinical Experience
- Provides expert level review of inpatient clinical records within 24-48 hours of admit
- Utilization review or coding experience (Preferred)
- Providing care for patients in the Department of Clinical Documentation Improvement
- Participates in seminars, in-service/educational efforts and activities sponsored by professional associations at the local, state, and national levels
- Communicates verbally, via email or writing with physician to obtain/clarify more specific documentation of the principal diagnoses, co- morbidities and complications
- Facilitating improvement to the overall quality and completeness of clinical documentation
Qualifications for clinical documentation improvement specialist
- Subject to a one year probationary period
- B) Successful completion of a course for medical technicians, hospital corpsmen, medical service specialists, or hospital training obtained in a training program given by the Armed Forces or the U.S. Maritime Service under close medical and professional supervision may be substituted on a month-for-month basis for up to six months of experience provided the training program included courses in anatomy, physiology, and medical record techniques and procedures
- Obtaining appropriate and accurate clinical documentation that reflects the severity of illness and risk of mortality for inpatient discharges and assigning a working DRG
- Interacting as an active member of the multi-disciplinary patient care team alongside physicians, allied health practitioners, case managers and other members of the patient care team to gather accurate and timely clinical information for abstraction into a designated CDIS database
- Querying physicians using the approved query process in order to obtain clinical information
- Adhering to the standards of ethical coding per AHA ICD-10 CM coding guidelines and MSKCC internal coding guidelines
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Clinical Documentation Improvement Specialist Job Description
Job Description Example
Our growing company is searching for experienced candidates for the position of clinical documentation improvement specialist. 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 specialist
- Educate assigned clients on procedures, processes, and best practices for implementation and use of M*Modal’s clinical documentation improvement technologies
- Direct interaction and training of physicians, CDI personnel and Coders
- Assist the Director of Implementation and Adoption for CDI with development and maintenance of M*Modal internal documentation and account management processes for support of CDI technologies
- Oversight and management of M*Modal CDI accounts
- Analysis of client data and trends, including performance and productivity metrics and reporting to management
- Provide input into product development based on user feedback and industry expertise
- Provide sales and marketing support by performing demos, attending trade shows and acting as subject matter expert
- Assisting with testing and providing feedback on customer-facing products
- Develop and/or update medical center policy memoranda pertaining to documentation improvement
- Serve as technical expert in health record content and documentation requirements
Qualifications for clinical documentation improvement specialist
- In-depth knowledge of the health information industry as related clinical documentation improvement and coding
- Knowledge of the physician and CDS workflow, particularly as related to Electronic Health Records
- Knowledge of HIPAA, JCAHO industry guidelines, regulations and standards
- Excellent analytic skills and ability to train others to perform same
- Familiarity with communication and training methods, especially in “virtual” environments
- Adept at learning to use new technology and learning new skills
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Clinical Documentation Improvement Specialist Job Description
Job Description Example
Our innovative and growing company is looking to fill the role of clinical documentation improvement specialist. To join our growing team, please review the list of responsibilities and qualifications.
Responsibilities for clinical documentation improvement specialist
- Recognizes opportunities for documentation improvement using strong critical-thinking skills
- Strategically educates members of the patient-care team regarding documentation regulations and guidelines, including attending physicians, allied health practitioners, nursing, and care management
- Performs ONSITE concurrent coding quality reviews for provider charts other teams as needed
- Performs accurate and timely concurrent review of selected inpatient admissions to include assignment of working DRG through identification of principal diagnosis and secondary diagnoses including conditions qualifying as complication/co-morbidities and major complications and that impact severity of illness (SOI), risk of mortality (ROI) and quality measures
- Maintains professional competency by keeping abreast of new coding issues and guideline
- Works with RCO Coding staff, physicians and Patient Accounts with regards to payment denials, medical necessity and documentation issues
- Meets with physician advisor regularly to discuss documentation challenges, areas of opportunity, and perform chart reviews as needed
- Assists with Joint Commission documentation standards
- Approaches conflict in a constructive manner, helps identify problems, offer solutions and participate in resolution
- Responsible to perform any and all other assigned duties as requested
Qualifications for clinical documentation improvement specialist
- Two to three years of experience with physician interaction
- Current FL RN License preferred
- Five years clinical experience in Acute Hospital setting
- Minimum 5 years recent health information management, case management / utilization / quality review and/or other related clinical experience in an acute care facility required
- An advance degree can be substituted for a PA RN license
- BSN degree, if RN
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Clinical Documentation Improvement Specialist Job Description
Job Description Example
Our growing company is looking to fill the role of clinical documentation improvement specialist. 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 specialist
- Collects information about patients’ diagnoses and enters it into computer databases
- Assesses all patient medical documents to ensure accuracy
- Tracks information on diseases
- Analyzes medical information to assist healthcare staff in providing superior services for patients
- Interprets clinical reports to identify health-related patterns and assists in addressing patient health problems
- Meets with clinical staff to explain reports
- Ensures that records are kept in proper order so that patients’ health information can be easily located
- Conducts research and performs administrative duties
- Takes continuing education courses and stays up-to-date on changes in laws governing clinical documentation
- Will take direction and guidance from Supervisor of the Risk Adjustment Coding and Documentation Improvement Specialist and the Manager of the Risk Adjustment Coding and Documentation Improvement Program
Qualifications for clinical documentation improvement specialist
- Associates degree or higher or significant equivalent work experience (3+ years)
- Minimum 1 year CMS Risk Adjustment – HCC Coding/Auditing Experience
- BSN degree if an RN
- 2+ CDI years and experience working in academic medical centers, primary care, or specialist outpatient setting
- Knowledge of EPIC and other EMR systems a plus
- Iowa City, IA 1 vacancy
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Clinical Documentation Improvement Specialist Job Description
Job Description Example
Our company is growing rapidly and is looking for a clinical documentation improvement specialist. If you are looking for an exciting place to work, please take a look at the list of qualifications below.
Responsibilities for clinical documentation improvement specialist
- Attendance at, and delivery of, WebEx or teleconference meetings and/or education sessions as necessary
- Performance of auditing and/or quality assurance tasks
- Communicate to the provider specific targeted quality measures that have consistently not been meet for the current year
- Provides daily support/mentoring/training to new hires existing staff
- Provides assistance in managing escalated issues and special projects as needed to supervisors and managers
- Performs concurrent and retrospective CDI audits
- Provides CDI support/mentoring/training to Physicans and hospital leadership as needed
- Completion of scrubbing and submitting monthly data to vendor
- Enters facility specific data to dashboards
- Resolves problems, concerns and reports issues with Operations Supervisor, Manager or Director
Qualifications for clinical documentation improvement specialist
- Able to organize and present information clearly and concisely
- Minimum of five years acute care nursing experience with specific medical/surgical, Intensive Care, post-acute care unit, or Emergency Department experience
- Graduate from a Nursing program, BSN, or graduate of Health Information Management RHIT, RHIA preferred
- BSN degree if a RN
- This full-time position provides CDI support to the Arizona/ Nevada Service Area Team by filling in when CDIS specialists are on paid time off/ leave, or when census at a particular hospital is higher than expected
- Assists the supervisors and managers with special projects, auditing and other duties as assigned