- Job Title:
- Clinical Doc Improvement Spec
- Job ID:
- Shared Services
- Full/Part Time:
- FTE %:
- Salary Range Min:
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Clinical Doc Improvement Spec (Job Opening 442338) - Scope of Position
The Clinical Documentation Improvement Specialist (CDIS) is a nurse or other clinically qualified individual who is responsible for concurrent review of inpatient medical records to identify opportunities for improving the quality of medical record documentation. Opportunities include identification of cases where diagnoses and procedures are either absent, not stated in appropriate terminology, or are not appropriately recorded. The CDIS will confer with the appropriate caregiver on the additional documentation that may be required. The Documentation Specialist?s goal is to achieve a complete medical record by the time of patient discharge in order to ensure quality documentation that reflect the patients? diagnoses, treatments, and severity of illness, and to facilitate and enhance the coding and DRG assignment process.
This position supports initiatives to improve the quality of documentation by all caregivers within the Ohio State University Health System with specific emphasis on improving documentation to support the coding process which ultimately improves the organization?s performance on quality measures and on the Case Mix Index (CMI) which is critical to the financial health of the organization. The CDIS follows Joint Commission (JC), Medicare and third party payor documentation guidelines and the official guidelines for assigning ICD-9-CM diagnosis and procedure codes in efforts to continually improve the quality of medical record documentation. The CDIS provides assistance to the attending physician and other health care providers in the patient care documentation process.
Education and experience
Bachelor's degree in nursing. Must possess strong clinical skills and ability to identify areas for improvement in documentation in the medical record. Preferably with experience with medical record coding (ICD-9-CM) and data analysis. Knowledge and experience with medical information computer applications, word processing and electronic spreadsheets.