Clinical Documentation Specialist II

at  Steward Health Care

POSITION SUMMARY:

The Clinical Documentation Integrity Specialist (CDIS) provides clinically based, concurrent and retrospective reviews of inpatient medical records. CDI strives to ensure accurate, complete, compliant, concise, and consistent documentation that reflects the true clinical scenario of the patient’s encounter. This additionally serves to reflect the true Severity of Illness (SOI), Risk of Mortality (ROM), and Intensity of Services (IOS) rendered to provide quality care and treatment to the patient. The Clinical Documentation Integrity Specialist serves as a liaison between leadership, medical staff, nursing, coding, case management and quality departments. Excellent communication skills and the ability to critically analyze are essential to successful CDI performance. The CDIS II is an intermediate level position for experienced and proficient CDI Specialists consistently meeting all criteria for CDIS I performance.

REQUIRED KNOWLEDGE & SKILLS:

(Examples: Ability to work independently and take initiative; Good judgment and problem-solving skills; Communication skills; Interpersonal and organizational skills; Level of confidentiality)

• Must possess strong organizational, communication and clinical foundation skills.
• Must demonstrate proficiency in EMR software, CDI applications (after education and orientation) and Microsoft applications.
• Demonstrates ability to multi-task and work efficiently and effectively between software platforms.
• Demonstrates the ability to communicate effectively in a fast-paced environment with multidisciplinary teams consisting of physicians, nurses, coders, administration, and other health care professionals.
• Demonstrates proficiency in CDI process after completion of onboarding and orientation/education. Continued improvement in proficiency and accuracy is expected during and after orientation/onboarding.
• Experienced CDI Specialists are expected to onboard more quickly and perform commensurate with experience level.
• Ability to work independently, prioritize tasks and demonstrate self-awareness in the workplace.
• Always maintains confidentiality and HIPAA compliance.

EDUCATION/EXPERIENCE/LICENSURE/TECHNICAL/OTHER:

I. Education: Bachelor’s degree in a clinical or coding study is preferred. Advanced degrees such as Master, Doctorate or Foreign Medical Graduate will require proof of degree status.
II. Experience: Minimum of 2-5 years acute clinical or coding (IP) experience preferred. A minimum of 1 or more years CDI experience required with proficiency consistently demonstrated.
III. Licensure/Certification: RN or LVN with current state license, proof of certification when applicable
IV. Software/Hardware: Proficiency in Microsoft applications, EMR applications, CDI, and coding software

(Use bullets for specific responsibilities)

• Provides clinically based, concurrent and retrospective reviews of inpatient medical records. Ensures documentation accurately reflects quality of care, severity of illness and risk of mortality to support correct coding, reimbursement, and quality initiatives.
• Proactively contacts physicians or other clinicians as needed to clarify procedures/diagnoses to ensure proper documentation. This includes providing information to physicians and other clinical staff.
• Performs initial case reviews and follow up reviews as indicated by CDI software. Performs timely and accurate completion of query reconciliation.
• Submits queries to providers as needed to ensure complete documentation of relevant diagnoses.
• Assigns diagnosis codes following the Official Guidelines for Coding and Reporting and AHA Coding Clinics to obtain an accurate working DRG.
• Promotes a partnership with Coding/HIM team to ensure the accuracy of principal diagnosis, procedures, and completeness of documentation to determine the working and final DRG, severity of illness and risk of mortality, risk adjustment, HCC, etc. Functions as a liaison between clinical and coding teams.
• Actively engages and participates in delivery of education to providers through extensive interaction one on one and in monthly medical staff and leadership meetings as appropriate.
• Promotes collaboration and engagement with physicians to support query education.
• Utilizes critical thinking skills and clinical reasoning to identify, clarify, and query for accurate representation of documentation to reflect appropriate clinical status of the patient. This impacts quality reporting, physician/facility/organization public data, reimbursement, public health data, and disease tracking and trending.
• Maintains professional competency in documentation and coding practices by keeping up to date on new coding guidelines, policies/procedures, federal and state reimbursement.
• Effectively communicates daily with the multidisciplinary team consisting of CMO/Physician advisor, providers, nurses, coders, administration, and others.
• All tasks must be performed in accordance with the established Steward CDI daily workflow with adherence to Inpatient CDI Handbook protocols.
• Communicates in a timely manner with CDI leadership, reporting potential and/or actual problems. Responds timely to emails and requests in a professional and courteous manner in accordance with CARES.
• Follows Steward query escalation process to address query response results that are untimely, missing, or inappropriate.
• Meets or exceeds CDI performance minimal standards:

o 20 reviews per 8 hours worked
o 30% query rate
o 93 % query compliance (AHIMA Guidelines)
o 20 % missed query opportunity

o 95% accuracy and in a timeliness for reconciliation

• May be requested to perform other related tasks, record reviews or responsibilities as assigned.
• Consistently demonstrates proficiency in engaging with providers in areas such as education, query follow-up, and face to face interactions through scheduled encounters.
• Actively mentors newer CDI Specialists through onboarding, side by side teaching and consistently being available as a resource to less experienced CDI Specialists.
• Participates and presents in facility-based meetings as assigned by CDI leadership.
• Proficiently performs second level reviews as assigned (special project focused reviews, etc.).
• Performs all the above functions with minimal supervision and optimal accuracy and efficiency.