Clinical Documentation Improvement Prebill Specialist

The Office of Clinical Documentation Improvement (CDI) at University of Iowa Health Care has an opening for a full-time Clinical Documentation Improvement Prebill Specialist.  The primary purpose of the CDI Prebill Specialist is to conduct discharge review of the medical record review, including coding and clinical documentation to increase the accuracy, clarity, and specificity of provider documentation and medical coding. The CDI Prebill Specialist is a professional Registered Nurse with a broad clinical knowledge base and understanding of DRG documentation requirements who works under the supervision of the CDI Supervisor and in collaboration with the CDI Director/Manager.

Qualifications

• A master’s degree in nursing (MNHP or MSN) with two years of recent (within the last 5 years) work experience as a Clinical Documentation Specialist or other CDI specialist is required.

~or~

• A bachelor’s degree in nursing with more than two years of recent (within the last 5 years) work experience as a Clinical Documentation Specialist or other CDI specialist is required.
• A license to practice nursing in Iowa is required.
• Must currently hold a Clinical Documentation certification
  • Certified Clinical Documentation Specialist (CCDS), or
  • Certified Documentation Improvement Practitioner (CDIP).
• Must currently hold (or will obtain within 3 months)
  • Certified Coding Associate (CCA), or
  • Certified Coding Specialist (CCS), or
• Other applicable inpatient medical coding certification.
• Professional written and verbal communication skills are required.
• Demonstrates the ability to provide effective education in a variety of styles, including formal presentations.
• Proficiency with computer software applications (i.e., Microsoft applications) is required.
• Demonstrates excellent interpersonal skills with physicians, nursing staff, and interdisciplinary team members as demonstrated through written and verbal communication is required.
• Demonstrated organizational, time management and problem-solving skills are required. 

 Experience

• Have obtained both CDI and Coding certifications
• Have experience with both concurrent and retrospective record review
• Have experience with quality documentation, including patient safety indicators (PSI) and hospital acquired conditions (HAC)
• Display excellent coding and clinical documentation skills
• Display effective professional communication
• Be able to adjust to change for improvement of work protocols and processes efficiently
• Be comfortable presenting trends and education in group settings.
• Be able to be successful working in both autonomous and team environments

CDI quality chart reviews include

• Review of at-risk charts with opportunities for improved quality documentation
• Retrospective reviews for query identification, documentation clarification, denials, or quality measures.
• Quality reviews focused on CDI quality elements, such as Mortality, Hospital Acquired Conditions (HAC), and other publicly reported patient quality or safety metrics (i.e., AHRQ Patient Safety Indicators)

Job Duties and Responsibilities

Establishes effective and collaborative relationships with members of the hospital community to improve accuracy and completeness of acute inpatient documentation, especially with providers, Health Information Management coding staff, hospital administration, and other patient caregivers. 

Demonstrates expertise of MS-DRGs, APR-DRGs, documentation opportunities, clinical documentation requirements, and inpatient quality/safety metrics, including but not limited to the elements below:

Clinical Documentation Integrity: Inpatient Pre-bill review

• Conducts record reconciliation and communicates effectively with hospital coding staff to assign an appropriate working DRG and ICD10 codes.
• Reviews all inpatient mortality cases with opportunity and shares findings regularly with leadership and the CDI team.
• Works closely with leadership and educator to ensure all opportunities identified are reported accurately each month.
• Consistently attends and participates in meetings related to projects, initiatives, education related to quality driven CDI.
• Provides ongoing and regular feedback to CDI team and leads regarding trends for all quality related measures impacted by CDI.
• Assists with record review and vacation coverage, as needed
• Assists with coding notifications on an as needed basis for additional coverage
• Documents appropriately in the 3M© 360 Clinical Documentation Improvement system.
• Demonstrates an understanding of the importance of capturing all potential secondary diagnosis for coding purposes.
• Maintains thorough and current knowledge of clinical care and treatment of assigned patient populations to critically assess appropriateness of documentation.
• Complies with departmental standards regarding attendance, documentation, departmental workflows, continuous quality improvement and statistics, departmental policies and procedures, and the Code of Ethics.
• Effectively collaborates and respectfully communicates with fellow CDI team members, the hospital coding team, and quality-driven workgroups to ensure appropriate CDI practices and accurate application of coding/documentation principals.
• Actively participate in office and/or intradepartmental committees.
• Performs other projects or responsibilities as assigned.

Quality Measures/ Clinical Denials

• Collaborates extensively with CDI/HIM partners to ensure all opportunities for quality improvement are identified and addressed on an ongoing basis
• Demonstrates expertise in use of Vizient risk variable tools and educates others for appropriate use of these tools.
• Participates in CDI quality related committees
• Works closely with CDI Leadership, Vizient Analyst and CDI Data Analyst to establish a working reporting structure for all areas of specialty, including CDI nurses and members of the coding team.
• Works closely with physician advisors to ensure charts identified with patient safety indicators and hospital acquired conditions are reviewed concurrently when possible or retrospectively when necessary.
• Reviews DRG mismatches and reports findings to the DRG variance committee as requested.
• Acts as a backup to the quality and clinical denials CDI nursing team, by assisting with denial reviews, and assuring appropriate action is taken within appeal time frames to address clinical denial.
• Utilizes multiple tools (MS, Tableau, Vizient, etc.) to ensure accurate tracking and reporting of clinical documentation integrity data.
• Collaborates with CDI/HIM Leadership and Physician Advisors in appropriately identified clinical denials requiring escalation.
• Maintains clinical expertise and trends in healthcare, reimbursement methodologies and utilization management specialty areas by participating in professional organizations, seminars and educational programs, as requested.

Internal Education

• Provides consistent education on clinical documentation opportunities, hospital coding and/or reimbursement issues, as well as performance improvement methodologies to all members of the hospital community.
• Identifies opportunities for provider education to improve medical record documentation for severity, morality of other risk adjustment variables. Provides ongoing education as needed for all areas of specialty.
• Reports findings and trends to hospital committees and initiatives as directed by leadership.