HIM CDI Ambassador

UofL Health - Louisville, KY

Louisville, KY

About the position

The CDI Ambassador will develop and maintain physician and medical staff relationships while acting as a liaison between the CDI Specialists, HIM, and the hospital's medical staff to facilitate accurate and complete documentation for coding and abstracting of clinical data, capture of severity of illness, acuity and risk of mortality and appropriate DRG assignment for optimal reimbursement. The Ambassador will provide education and assistance to physicians and medical staff regarding documentation compliance questions, CDI physician queries, and clinical preciseness that truly reflects the patient's care and treatment course. Responsible for reviewing patient medical records to facilitate modifications to clinical documentation through concurrent (pre-bill) interaction with providers and other members of the healthcare team to promote accurate capture of clinical treatment (later translated into coded data) and to support the level of service rendered to relevant patient populations. Exhibits expert knowledge of clinical documentation requirements, MS-DRG Assignment, case mix index (CMI) analysis, clinical disease classifications, major and non-major complications and comorbidities (MCCs or CCs), and quality-driven patient outcome indicators. Interacts as needed with internal customers to include but not limited to hospital staff, physicians, residents, and other revenue cycle team members. Actively participates in department and hospital performance initiatives when needed to ensure ULH success.

Responsibilities

• Finalize unanswered open queries between CDI specialists and physicians.
• Complete initial medical record reviews of all inpatient patient accounts (all payers) within 24-48 hours of admission for a specified patient population.
• Evaluate and review inpatient medical records daily, concurrent with patient stay, to identify opportunities to clarify missing or incomplete documentation.
• Assign the principal diagnosis, pertinent secondary diagnoses, procedures for accurate MS-DRG assignment, score risk of mortality and severity of illness and initiate a review worksheet.
• Conduct follow-up reviews of patients every 2-3 days to support and assign a working or final MS-DRG assignment upon patient discharge, as necessary.
• Spend a minimum of 50% of the workday in the hospital as a physician resource, developing physician and medical staff relationships.
• Provide ongoing physician and medical staff education regarding documentation, queries, coding guidelines, clinical terminology and coding updates.
• Collaborate with the Quality department and physicians to identify and resolve documentation patterns and discrepancies.
• Provide new medical staff orientation regarding clinical documentation and physician documentation responsibilities.
• Provide and develop in coordination with the CDI manager current documentation tip sheets to enhance accurate and complete documentation and coding.
• Recommend changes to documentation templates and physician queries based on coding changes, regulatory modifications, and quality review findings.
• Coordinate training and education for Coding Specialists and CDI staff when trends are identified.
• Provide on-call service for physician and medical staff query questions and education.
• Refer potential and identified HAC's (hospital acquired conditions), PSI's (Patient Safety Indicators) and preventable hospital HARM's to the Quality department.
• Maintain CDI department database and spreadsheets on medical staff education regarding documentation, queries, coding guidelines, medical terminology and coding updates.
• Formulate clinically, compliant and credible physician queries regarding missing, unclear or conflicting health record documentation.
• Proactively collaborate with physicians to discuss and clarify documentation inconsistencies.
• Educate providers about identification of disease processes that reflect SOI, complexity, and acuity.
• Gather and analyze information pertinent to documentation findings and outcomes and use this information to develop action plans for process improvements.
• Collaborate with case managers, nursing, and other ancillary staff regarding interaction with physicians concerning documentation opportunities.
• Communicate/completes Clinical Documentation Improvement (CDI) activities and coding issues for appropriate follow-up and resolution.
• Remain abreast and current on training of new hires and ongoing CDIS professional staff development.
• Collaborate with HIM/coding professionals to review and resolve DRG mismatches for individual problematic cases.
• Identify patterns, trends, variances, and opportunities to improve documentation review processes.
• Aid in identification and proper classification of complication codes and present on admission (POA) determination.
• Contribute to a positive working environment and perform other duties as assigned.

Requirements

• Bachelor's degree in Nursing, Healthcare Administration or HIM required.
• 3+ years of acute care experience as a RN or 3+ years inpatient coding experience.
• Prior experience with 3M 360 Clinical Application and Cerner PowerChart preferred.
• Prior advanced clinical expertise and extensive knowledge of complex disease processes with broad clinical experience in an inpatient setting.
• Active RN license (KY), RHIA or possess an active (AHIMA) CCS or (AAPC) CPC-H or CIC certified coding credential required.
• AHIMA CDIP or ACDIS CCDS clinical certifications required or if hired without, must obtain within 12 months of employment.