Clinical Documentation Specialist - Full Time
Clinical Documentation Specialist - Full Time
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Job Description
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The Clinical Documentation Integrity Specialist (CDIS) performs clinically based health record reviews to facilitate and obtain appropriate provider documentation for clinical conditions and procedures to reflect severity of illness accurate coding/DRG expected risk of mortality accuracy of patient outcomes and complexity of patient care. Through compliant query processes and education clarifies incomplete conflicting ambiguous and/or missing provider documentation. The CDIS 1 works in collaboration with other CDI Specialists coders quality analysts providers and other members of the healthcare team to ensure accurate highquality clinical documentation to support UHealth initiatives. Adheres to departmental and organizational goals objectives standards of performance policies and procedures continually ensuring quality documentation and regulatory compliance.
Ensures accuracy completeness and quality of clinical information used for measuring and reporting physician and hospital outcomes.
Performs thorough and timely medical record reviews to identify potential gaps or opportunities to facilitate improved provider documentation.
Follows designated case review workflows including initial continued stay retrospective and final CDI reviews.
Ensure clinical documentation accurately reflects the level of care rendered severity of illness risk of mortality and clinical validation (in compliance with government and other regulations).
Demonstrates proficiency with ICD10CM/PCS APR DRG and MS DRG by assigning accurate working DRGs based upon identification and selection of principal diagnosis complications coexisting or comorbid conditions POA indicators and significant procedures.
Ensures documented conditions clarifications and coded diagnoses are clinically supported.
Follows up on queries per policy including reviewing for continued appropriateness and updating pending queries as needed.
Recognizes opportunities for documentation improvement using strong criticalthinking skills and sound judgment in decision making keeping integrity and compliance at the forefront of considerations in addition to outcomes reimbursement and regulatory requirements.
Facilitates highquality documentation by utilizing queries that are effective clear concise and compliant in accordance with latest AHIMA/ACDIS Query Practice Brief.
Makes recommendation of possible refinement of principal diagnosis secondary diagnoses and/or procedures based on clinical data to facilitate appropriate DRG assignment.
Records review findings and other data elements timely and accurately into CDI Software and other data mechanisms to support data integrity for reporting.
Effectively and appropriately communicates and collaborates with providers HIM/coding quality CDI and other members of the healthcare team.
Professionally interacts with providers to complete/resolve queries provide education and/or answer questions as needed.
Escalates concerns with query responses DRG reconciliation notifications etc. as appropriate or per departmental protocol.
Performs timely reconciliation of working codeset/DRG compared to final codeset/DRG. Effectively communicate discrepancies with coding including rationale and supporting evidence. Escalate as appropriate.
Demonstrates willingness to learn and accepts feedback productively.
Meets and maintains CDI quality and query compliance standards.
Works independently; demonstrates effective time management and prioritization of tasks. Maintains productivity standards.
Perform duties and conduct interpersonal relationships in a manner that promotes a team approach and collaborative work environment with physicians CDI staff and coders.
Assumes responsibility for professional development through participation at workshops conferences and/or inservices and maintains appropriate records of participation.
Complies with and ensures adherence to HIPAA and Code of Conduct policies.
Other duties as assigned.
Education:
Bachelors degree in Nursing Health Information Management or related medical field required. Graduate Foreign Medical degree will be considered.
Certification and Licensing:
Current RN MD or RHIA required
CCDS or CDIP certification preferred; shall obtain CCDS or CDIP within 3 years from date of hire
Coding certification (CCS CIC or CPC) preferred
Experience:
At least two 2 years direct patient care in acute care setting or 3 years inpatient coding experience required. Prior clinical documentation improvement (CDI) experience preferred.
Demonstrated extensive clinical knowledge criticalthinking skills and understanding of disease processes anatomy pathophysiology and disease management/treatment required.
Proficiency with Microsoft Office (Excel PowerPoint Word Outlook) required.
Proficiency with technology/software required. Experience with 3M 360 Encompass preferred.
Excellent written and verbal communication skills; ability to write concisely and effectively when communicating with providers.
The University of Miami offers competitive salaries and a comprehensive benefits package including medical dental tuition remission and more.
UHealthUniversity of Miami Health System South Floridas only universitybased health system provides leadingedge patient care powered by the ground breaking research and medical education at the Miller School of Medicine. As an academic medical center we are proud to serve South Florida Latin America and the Caribbean. Our physicians represent more than 100 specialties and subspecialties and have more than one million patient encounters each year. Our tradition of excellence has earned worldwide recognition for outstanding teaching research and patient care. Were the challenge youve been looking for.
The University of Miami is an Equal Opportunity Employer Females/Minorities/Protected Veterans/Individuals with Disabilities are encouraged to apply. Applicants and employees are protected from discrimination based on certain categories protected by Federal law. Click here for additional information.
Job Status:
Full timeEmployee Type:
StaffPay Grade:
H12Required Experience:
Unclear Seniority
Employment Type
Full-Time
