About the position
The Clinical Documentation Improvement Specialist (CDIS) plays a crucial role in ensuring the accuracy and completeness of medical records, which is essential for assessing the severity of illness and maintaining quality standards within the healthcare system. This position involves a comprehensive review of medical records, requiring extensive interaction with physicians, health information management professionals, and nursing staff. The CDIS is expected to actively participate in team meetings and contribute to the education of staff regarding the Clinical Documentation Improvement Program (CDIP) process. This role is vital in promoting best practices in documentation, which ultimately impacts patient care and hospital reimbursement processes. In this position, the CDIS will be responsible for reviewing medical records for completeness and accuracy, particularly focusing on the severity of illness (SOI) and quality metrics. Utilizing the Compliant Documentation Management Program, the specialist will perform timely record reviews, identify opportunities for documentation improvement, and initiate severity illness worksheets for inpatient cases. The role also requires formulating clinically credible documentation clarifications and effectively communicating with physicians to request necessary documentation clarifications related to SOI, Core Measures, and Patient Safety. The CDIS will be expected to follow up on all cases requiring documentation clarifications and resolve discrepancies in collaboration with coders. Accurate data input into tracking systems is also a key responsibility, along with performing any other related duties as assigned. This position demands a high level of organizational, analytical, and interpersonal skills, as well as a solid understanding of clinical processes and coding guidelines.
Responsibilities
- Facilitates accurate documentation for severity of illness and quality in the medical record.
- Reviews medical records for completeness and accuracy for severity of illness (SOI) and quality using the Compliant Documentation Management Program documentation strategies.
- Performs accurate and timely record review.
- Recognizes opportunities for documentation improvement.
- Initiates severity illness worksheet for inpatient cases.
- Formulates clinically credible documentation clarifications (queries).
- Requests documentation clarifications as appropriate for SOI, Core Measures, and Patient Safety.
- Communicates effectively and appropriately with physicians.
- Timely follows up on all cases and resolves those with clinical documentation clarifications.
- Participates in Task Force Meetings (Coder/CDI).
- Communicates with coders and resolves discrepancies.
- Performs accurate input data into the tracking system.
- Performs all other related duties as assigned.
Requirements
- Graduation from a program of nursing, BSN preferred.
- Current state Registered Nurse license.
- Score a minimum of 70% on the Clinical Competency Assessment (CCA).
- 5 years of adult acute care experience in med/surg, critical care, emergency room, or PACU.
- Strong organizational, analytical, writing, and interpersonal skills.
- Dependable, self-directed, and pleasant demeanor.
- Critical thinking, problem-solving, and deductive reasoning skills.
- Knowledge of Pathophysiology and Disease Process.
- Basic computer skills, familiarity with Windows-based software programs.
- Knowledge of disease processes in all clinical specialties, anatomy & physiology, and pharmacology, with the ability to correlate abnormal lab results to disease processes.
- Knowledge of official coding guidelines and documentation requirements related to the Inpatient Prospective Payment System.
- Knowledge of the regulatory environment.
- Understanding and communication of differences between Medicare Part A and Part B guidelines and their impact on DRG assignments.
- Knowledge of Core Measure and Patient Safety Indicators.
