Description
The Clinical Documentation Integrity Specialist (CDI) is responsible for utilizing independent clinical judgement in facilitating the integrity, overall quality, accuracy, and completeness of provider-based clinical documentation in the medical record. This position is responsible for collaborating with healthcare providers to ensure the documentation in the medical record accurately reflects the severity of illness and risk of mortality of the patient. The CDI Specialist assesses the clinical documentation through extensive reviews of the medical record, interaction with all members of the healthcare team and the Healthcare Information Management (HIM) Coding team to ensure appropriate coding and Diagnosis Related Group (DRG) assignment for the level of services rendered to the patient and to ensure that the clinical information utilized in profiling and reporting outcomes is complete and accurate.
Roles and Responsibilities
- Ensures determination of working Diagnosis Related Group (DRG) assignment and applying clinical expertise to identify opportunities for improved or clarified documentation that accurately reflects the severity of illness (SOI) and risk of mortality (ROM) of the patient.
- Direct and timely follow-up with clinical providers to ensure requested clarification is provided.
- Learn clinical documentation integrity (CDI) skills (research, technology, treatment modalities, etc.).
- Utilize critical thinking/problem solving processes in chart review process to determine diagnoses and procedures.
- Learn to utilize professional association resource materials and regulatory agencies guidelines to enhance own skill sets: Coding Clinics, American Health Information Management Association (AHIMA), Association of Clinical Documentation Integrity Specialists (ACDIS), Centers for Medicare and Medicaid Services (CMS) guidelines.
- Learn and gain knowledge of writing concurrent and retrospective queries for clarification of information in the medical record necessary to appropriately assign diagnoses and procedures.
- Learn to establish and reconcile Diagnosis Related Group (DRG) processes compliant with departmental guidelines and Centers for Medicare and Medicaid Services (CMS) regulations.
- Reconciles all cases in Clinical Documentation Integrity (CDI) database 80% of the time; determined by quality audit, after training.
Other Functions
- Work with Clinical Documentation Integrity (CDI) manager, Clinical Documentation Integrity (CDI) educator and team preceptors to learn about proper reviewing procedures selection of primary and secondary diagnoses, and the impact a proper chart revenue contributes to the revenue cycle.
- Apply knowledge of health care workflows to work collaboratively with medical staff and other health care team members to improve the overall accuracy and comprehensiveness of medical record documentation, with focus on ensuring accurate reporting of quality outcomes.
- Learn the impact of accurate clinical documentation in the medical record and establishing the Primary Diagnosis.
- Meet established operational and productivity standards.
- Learn the use of the Clinical Documentation Integrity (CDI) business platform [3M, PowerChart, Cerner].
- Performs other duties as assigned.
- Ability to perform duties Monday through Friday, 40-hour work week.
- Maintain Centra Health policies and procedures, including vaccinations, etc.
- Responsible and accountable for expanding own nursing and Clinical Documentation Integrity knowledge.
- Must maintain registered nurse licensure.
Education
- Diploma or Associate Degree in Nursing.
Work Experience
- Five years or more years clinical nursing experience, preferably in an intensive clinical nursing environment.
- Excellent Computer Skills.
Licenses & Certifications
- Registered Nurse in the State of Virginia or compact state.
Licenses & Certifications(Preferred)
- ACDIS CDI Apprenticeship Certification.