Clinical Documentation Improvement Specialist II at Emory Healthcare

Atlanta, Georgia, United States -

Full Time

Start Date

Immediate

Expiry Date

08 Sep, 26

Salary

54.95

Posted On

10 Jun, 26

Experience

5 year(s) or above

Remote Job

Yes

Telecommute

Yes

Sponsor Visa

Skills

Clinical Documentation Improvement, Clinical Review, Medical Record Review, Clinical Coding, Query Compliance, Conflict Resolution, Patient Safety Indicators, Hospital Acquired Conditions, Medical Auditing, Acute Care Nursing, DRG Validation, Onboarding and Training

Industry

Hospitals and Health Care

Description

Overview Be inspired. Be rewarded. Belong. At Emory Healthcare. At Emory Healthcare we fuel your professional journey with better benefits, valuable resources, ongoing mentorship and leadership programs for all types of jobs, and a supportive environment that enables you to reach new heights in your career and be what you want to be. We provide: Comprehensive health benefits that start day 1 Student Loan Repayment Assistance & Reimbursement Programs Family-focused benefits Wellness incentives Ongoing mentorship and leadership programs And more! Description JOB DESCRIPTION: Capable clinician who has acquired broad experience in performing clinical reviews to facilitate the overall quality, completeness, timeliness, and accuracy of clinical documentation in the patient record to support the delivery of high-quality patient care, adherence to quality standards, the clinical coding process and appropriate hospital reimbursement. Serves as a resource and preceptor to colleagues assisting with peer reviews as required. Demonstrates development of analytical skills in identifying clinical documentation improvement opportunities upon medical record review. Recognizes the impact of CDI on compliance, quality patient outcomes and appropriate hospital reimbursement. Continues to recognize own performance limitations, but requires minimal assistance. Demonstrates a score of > 93% on the previous two quality assessments for the following KPIs: query compliance, PDx accuracy, and opportunity captured percentage. Implements quality CDI reviews independently. Manages time effectively. Functions in a developing leadership role. Orients staff as assigned in absence of designated preceptor. Demonstrates effective listening skills. Reduces barriers to facilitate communication. Utilizes effective conflict resolution skills. Has awareness of one's own values and how they affect interactions and relationships. May seek assistance to resolve complex issues. Respects and maintains confidential information. Accepts personal accountability for professional development and growth. Meets all CDS I Employee Commitments. Incumbent may work under close supervision following established routines or assigned work with limited employee latitude. Employee may work under general supervision and receives general guidance on work priority with substantial employee latitude. Employee may work independently under the general direction of their leader. Assist with the onboarding, training and development of New CDI staff. Be a resource for New and Junior CDI staff across Emory Healthcare. Assist in random quality reviews to ensure accurate and compliant chart review process, ensure consistent query compliance. Maintain dynamic communication with coders and CDI personnel to identify root cause of CDI-Coder final DRG mismatch and seek to resolve incongruence with appropriately assigned final DRG. Performs concurrent and retrospective reviews of the medical record (as needed), utilizing evidence-based knowledge, protocols and criteria. Conducts follow-up reviews of clinical documentation to ensure points of clarification have been recorded in the patient's chart. Be essential in supporting the Hospital Value-Based Purchasing (VBP) results, by reviewing documentation to ensure accuracy in the Patient Safety Indicators (PSI), Hospital Acquired Conditions (HAC), Present on Admission (POA) conditions, and Mortality reviews to avoid penalties associated with lack of proper documentation. MINIMUM QUALIFICATIONS: Graduate of an accredited school of nursing or Foreign medical graduate from an accredited medical school. Current licensure as a Registered Nurse in the state of Georgia. Minimum of 3 years recent clinical experience in an acute care setting, (Critical Care, Medical/Surgical or Emergency department nursing preferred; or 2 years experience in a specialty area.) Required Certification(s): CCDS by ACDIS or CDIP by AHIMA + 3 plus years of CDI experience. 5+ years in healthcare related field with strong clinical expertise and acumen. PHYSICAL REQUIREMENTS: (Light 1-10 lbs): 0-33% of the work day (occasionally), negligible 34-66% of the workday (frequently), negligible 67-100% of the workday (constantly). Lifting 10 lbs max, carrying of small articles such as dockets, ledgers, files, small tools, occasional standing & walking, frequent sitting, close eye work (computers, typing, reading, writing), Physical demands may vary depending on assigned work area and work tasks. ENVIRONMENTAL FACTORS: Factors affecting environment conditions may vary depending on the assigned work area and tasks. Environmental exposures include, but are not limited to: Blood-borne pathogen exposure, Bio-hazardous waste. chemicals/gases/fumes/vapors, communicable diseases, electrical shock , floor surfaces, hot/cold temperatures, indoor/outdoor conditions, latex, lighting patient care/handling injuries, radiation, shift work, travel may be required, use of personal protective equipment, including respirators, environmental conditions may vary depending on assigned work area and work tasks. Additional Details Emory is an equal opportunity employer, and qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, protected veteran status or other characteristics protected by state or federal law. Emory Healthcare is committed to providing reasonable accommodations to qualified individuals with disabilities upon request. Please contact Emory Healthcare’s Human Resources at careers@emoryhealthcare.org. Please note that one week's advance notice is preferred.

Responsibilities

Perform concurrent and retrospective clinical reviews to ensure the accuracy, completeness, and timeliness of patient records for appropriate reimbursement and quality care. Support Hospital Value-Based Purchasing results by reviewing Patient Safety Indicators and Hospital Acquired Conditions while mentoring junior CDI staff.