Clinical Documentation Integrity Specialist

Responsibilities

• Completes a concurrent review of the medical record for assigned patients in the required timeframe.
• Performs daily case reviews and identifies diagnoses and procedures in order to assign in accurate working DRG. Performs follow-up medical record reviews to identify any additional diagnoses or procedures that may impact the DRG assignment. Confers with coders to ensure appropriate final DRG and completeness of supporting documentation.
• Develops physician education strategies to promote complete and accurate clinical documentation and correct negative trends. Confers with nursing, case management, utilization review and other clinical caregivers to explain the importance of clear and concise documentation.
• Collects and analyzes data showing the activities performed, results of interactions, improvements made in clinical documentation, and distribution of DRGs and case mix index.
• Organization Expectations, as applicable:
• Demonstrates ability to provide care or service adjusting approaches to reflect developmental level and cultural differences of population served
• Partners with patient care giver in care/decision making.
• Communicates in a respective manner.
• Ensures a safe, secure environment.
• Individualizes plan of care to meet patient needs.
• Modifies clinical interventions based on population served.
• Provides patient education based on as assessment of learning needs of patient/care giver.
• Fulfills all organizational requirements
• Completes all required learning relevant to the role
• Complies with and maintains knowledge of all relevant laws, regulation, policies, procedures and standards.
• Fosters a culture of improvement, efficiency and innovative thinking.
• Performs other duties as assigned

Required Qualifications

• Associates Degree in Nursing or Health Information Management (HIM) degree or related field or equivalent experience
• 2 years Acute/Inpatient experience as an RN or 5 years inpatient coding experience
• Knowledge of clinical documentation requirements related to regulatory and reimbursement rules and regulations
• Knowledge of current coding and DRG classification systems
• Knowledge of medical terminology, anatomy and pathophysiology, pharmacology, ancillary test results
• Knowledge of ICD-10-CM and DRG classification systems
• Knowledge of physician and nursing unit practices
• Excellent interpersonal, critical thinking and conflict management skills
• Computer and data analysis skills
• Excellent verbal and written communication and presentation skills
• Analytical Thinking: Ability to identify issues, obtain relevant information, relate and compare data from different sources and identify alternative solutions
• Attention to detail: Achieve thoroughness and accuracy when accomplishing a task
• Critical Thinking: Gathers and integrates critical information, recognizing and addressing underlying assumptions of others to arrive at effective solutions
• Medical Staff Relations: Builds effective partnerships with medical staff, physicians, fostering open lines of communications and establishing trust
• Problem Solving: Identifies problems, determines accuracy and relevance of information, utilizes appropriate tools and staff resources along with sound judgment to generate and evaluate alternatives and to make recommendations
• Written Communication: Ability to organize and express information and ideas in written form to individuals as well as groups. Constructs messages that are clear and convincing
• Registered Nurse of MN Upon Hire or
• current Registered Health Information Administrator (RHIA) MN Board of Nursing or American Health Information Management Association Upon Hire or
• Registered Health Information Tech (RHIT) MN Board of Nursing or American Health Information Management Association Upon Hire

Preferred Qualifications

• Bachelors Degree in Nursing for candidate’s with nursing experience
• 5 years acute care nursing or
• 5 years inpatient coding experience
• Certified Clinical Documentation Specialist (CCDS) for candidate’s with HIM experience American Health Information Management Association Upon Hire

$81,702.40- $115,336.00 Annual