Clinical Doc Improvement Splst ll

Key Skills

Analytical and Problem solving, Environmental, Management, Microsoft Office suites, Natural Language Processing (NLP), US Healthcare Recruitment, Writing

Job Description

The Clinical Documentation Improvement Specialist II (CDIS II) is a responsible for facilitating the improvement in the overall quality and completeness of provider-based clinical documentation in the medical record by working directly with providers. This position is responsible for assisting treating providers to ensure that documentation in the medical record accurately reflects the severity of illness, risk of mortality, complexity of patient care, and hierarchal condition categories of the patient. The CDIS assesses clinical documentation through extensive medical record review, deployment of artificial intelligence, and collaborating directly with the providers to clarify the documentation to accurately and completely reflect the patients’ medical conditions. The collaboration with physicians, mid-levels, nursing staff, other patient care givers will be accomplished with on-site meetings and education, zoom meetings, telephonic discussions, rounding and email.

Additionally, the CDIS II will collaborate with the Health Information Management (HIM) coding staff and the Provider Documentation Educators to ensure that appropriate reimbursement is received for the level of services rendered to patients, clinical information utilized in profiling and reporting outcomes is complete and accurate.

The Ideal Candidate:

• Ability to recognize opportunities for documentation improvement and hold collaborative discussions with providers to address the opportunities in documentation.
• Proficient in computer skills including: MS Office, Optum 360 eCAC, Cerner EHR
• Organized, analytical, superior interpersonal and writing skills
• Dependable, self-directed with critical thinking, problem solving, and deductive reasoning
• Knowledge of pathophysiology and disease processes
• Knowledge of healthcare regulatory environment
• Knowledge of Medicare, Medicaid and Commercial payers, with the ability to communicate differences in guidelines and how they impact DRG or APR assignment
• Understand and support clinical documentation management strategies
• Must be flexible to accommodate clinician schedules
• Knowledge of Medicare, Medicaid and Commercial payers regulations, charging and coding guidelines
• Knowledge of Case Mix Index and how it is influenced

Responsibilities:

• Perform extensive record review
• Continuous interaction and education with physicians, mid-levels, nursing staff to include case management/utilization review, Quality, and Health Information Management (HIM) professionals.
• Utilizes software systems and the Natural Language Processor (NLP) functionality to perform duties.
• Concurrently identify opportunities for documentation improvement and collaborate with providers timely to clarify documentation. 
• Report clinical documentation improvement metrics and activities to the Medical Executive Committee via the Medical Records Committee or other committees as directed.
• Perform other duties as assigned.

Credentials and Experience:

• Associate’s Degree required. Nursing diploma or equivalent may substitute for Associate’s Degree.
• A minimum four (4) years of experience in an acute care setting; knowledge of care delivery documentation systems and related medical records documents; strong broad-based clinical knowledge and understanding of pathology/ physiology of disease processes.
• Registered Nurse (RN) license. *In Lieu of RN license, a medical certificate with a Certified Clinical Documentation Specialists (CCDS) from ACDIS or Certified Documentation (CDIP) from AHIMA, certification may be accepted.

Preferred:

• Experience in oncology and/or critical care nursing.