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Clinical Documentation Improvement Specialist
R00049326 Hello, Thank you for your interest in career opportunities with the University of Mississippi Medical Center. Please review the following instructions prior to submitting your job application:
- Provide all of your employment history, education, and licenses/certifications/registrations. You will be unable to modify your application after you have submitted it.
- You must meet all of the job requirements at the time of submitting the application.
- You can only apply one time to a job requisition.
- Once you start the application process you cannot save your work. Please ensure you have all required attachment(s) available to complete your application before you begin the process.
- Applications must be submitted prior to the close of the recruitment. Once recruitment has closed, applications will no longer be accepted.
Important Applications Instructions:
Please complete this application in entirety by providing all of your work experience, education and certifications/ license. You will be unable to edit/add/change your application once it is submitted.Job Requisition ID:
R00049326Job Category:
NursingOrganization:
Rev Cycle - HIM CDILocation/s:
Jackson Medical MallJob Title:
Clinical Documentation Improvement SpecialistJob Summary:
Supports and reviews the inpatient medical record in order to facilitate improvement in overall quality, completeness, clinical severity, and accuracy of inpatient clinical documentation for DRG based or APR based payor population for specific departments or areas. Obtains and promotes appropriate clinical documentation through extensive interaction with physicians and other members of the healthcare team.Education & Experience
Education and Experience Required: Three (3) years of clinical nursing experience in Acute Care, Utilization Review, Case Management, and/or Quality Management. Certifications, Licenses, or Registration required: Valid RN license, CCDS (Certified Clinical Documentation Specialist) Preferred Qualifications: Three (3) years of related hospital-based clinical documentation experienceKnowledge, Skills & Abilities
Knowledge, Skills, and Abilities: Demonstrates knowledge of evidence-based clinical guidelines across diverse conditions and age groups, as well as resource and utilization management, cost, and quality issues. Skilled in the use of personal computers and Microsoft Office Suite (Excel, PowerPoint, Word, Outlook) and other related software applications. Able to manage multiple priorities under time constraints, analyze problems, and make sound decisions. Possesses excellent verbal and written communication skills and strong interpersonal abilities to collaborate effectively across departments and business units, fostering a team-oriented environment. Healthcare revenue cycle experience is preferred. Responsibilities- Highly skilled authority regarding accuracy of reviewing inpatient charts within 24-48 hours of admission to ensure accuracy and completeness and identifies documentation opportunities that reflect severity of illness, acuity, and resource consumption. Assigns a working DRG based on principal diagnosis and procedure. Identifies comorbidities and complications. Accurately identifies present on admission diagnoses. Identifies quality issues and reports to the responsible party. Has advanced decision-making capabilities a with high developed degree of accuracy.
- Reviews and enters information in both epic and 3m 360 as required. Has advanced abilities in using these software systems.
- Highly skilled authority regarding accuracy of reviewing inpatient charts every 24-48 hours as a follow up. Identifies documentation that reflects the severity, acuity, quality issues and resource consumption and updates his/her findings in 3m 360 software. Accomplished in quality and production.
- Skillfully communicates with physicians and other patient care providers, both verbally and written in a clear and concise way, regarding documentation opportunities for improvement. Assists in development and presentation of educational materials regarding documentation for both cdi staff and/or providers and other members of the healthcare team.
- Demonstrates competent and effective assessment skills to identify clinical indicators for diagnoses. Integrates new or current techniques (of procedures or surgery, cdi issues, opportunities for documentation improvement) to obtain information as it relates to the planning, implementing, and evaluating of patient care documentation.
- Serves as subject matter expert and actively participates in the cdi department as a problem solver. Trends issues with denials for team education. Expertise in query development, guidelines, and standards.
- Serves as a cdi department liaison for providers and administrative meetings
- Serves as a database manager for cdi tracking tools, including DRG validation and reconciliation for accurate and timely reporting of cdi generated reimbursement, case index and production improvement. Gathers and analyzes information pertinent to documentation findings and outcomes.
- Serves on internal institutional committees as requested by management
- Must maintain a current ACDIS certification status. Participates in cdi-related continuing education activities to maintain certifications and licensures.
- Ability to formulate a more complex query in order to obtain clarifications of conflicting, ambiguous, or non-specific documentation, by verbal or written compliant queries. Ability to determine when it is appropriate to escalate an issue to senior team member, provider, or administrator.
- Has a highly developed understanding of what constitutes a risk management and/or quality program reporting (patient safety indicators-psi/hospital-acquired conditions-hac or mortality) cases. Aids other team members in identification and proper classification of complication codes, patient safety indicators/hospital-acquired conditions by acting as an intermediary between him/coding staff and medical staff.
- Expert understanding of what constitutes a risk management and/or quality program (PSI/HAC) case, and discusses with management, as appropriate.
- Works independently but collaborates appropriately with cdi management and him/coding management to review individual problematic cases and/or educational needs, as needed.
- Conducts independent research to promote knowledge of clinical topics, coding guidelines, regulatory policies and trends, and healthcare economics.
- The duties listed are general in nature and are examples of the duties and responsibilities performed and are not meant to be construed as exclusive or all-inclusive. Management retains the right to add or change duties at any time.