- Job Title:
- Clinical Doc Imprvmt Spec-Lead
- Job ID:
- Shared Services
- Full/Part Time:
- FTE %:
- Salary Range Min:
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Clinical Doc Imprvmt Spec-Lead (Job Opening 433048) - Scope of Position
The Clinical Documentation Improvement Specialist (CDIS) is a nurse 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 provider 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, severity of illness, risk of mortality and to facilitate and enhance the coding accuracy and DRG assignment process. Develops and manages educational programs for the CDI team that promotes quality documentation in the medical record in order to enhance the coding accuracy in support of high quality patient care, and operations. Prepares and presents educational sessions to the clinical documentation improvement specialists to increase knowledge base. Completes chart reviews of the CDIS team members to verify query accuracy, missed opportunities for chart completion and educational needs. Stays up to date on current changes with a CDI focus. This individual works closely with the Associate Director of Documentation Enhancement in support of educational materials and direction. Involved in the direction and education of all phases of the Clinical Documentation process and will be held accountable to work in a collegial manner with physicians, CDI staff, and other health care providers. Assumes responsibility for the professional development by participating in workshops, conferences, and/or in-services and maintains appropriate records of participation.
This position supports initiatives to improve the quality of documentation by all providers within the Ohio State University Health System with specific emphasis on CDI education, retrospective chart reviews of the CDI team and improving medical record documentation to support the coding process which ultimately improves the organization?s performance. With emphasis on quality measures and on the Case Mix Index (CMI) which is critical to the financial health of the organization. The CDIS Leader 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 Leader provides assistance to the attending physicians and other health care providers in the patient care documentation process. The CDIS Leader develops programs for the CDI team by referencing the official coding guidelines for assigning working DRG?s. Develops and implements programs and monitors the CDIS team for increased preparedness for ICD-10 through anatomy/physiology, pathophysiology and various educational programs. The CDIS Leader develops and grades CDIS competency tests. Works closely with the Associate Director in the orientation and ongoing training needs of the CDI team. Completes chart reviews determined by Associate Director to provide feedback on program success and educational needs for team. To support Associate Director in assisting with employee issues in his/her absence. Ability to interpret, adapt, and apply guidelines and procedures. Maintains the ability to analyze complex clinical scenarios and apply critical thinking skills. Has knowledge of reimbursement systems, federal, state, and payer-specific regulations and policies pertaining to documentation and coding. Knowledge of treatment methodology, patient care assessment, data collection techniques and coding classification systems is necessary. Serves as a resource on DRG issues. Other duties as assigned to meet the needs of the department.
Education and experience
Bachelor's degree in nursing required. Certified in Clinical Documentation Improvement preferred. Must possess strong clinical skills and ability to identify areas for improvement in documentation in the medical record. Must be able to develop professional educational programs and ability to provide instruction and guidance on the rules and regulations that govern the CDI program. Strong interpersonal skills, public speaking and leaderships skills a must. Experience with medical record coding (ICD-9-CM), ICD-10 and data analysis. Advanced clinical expertise and extensive knowledge of complex disease processes with broad based clinical experience in an inpatient setting. Knowledge and experience with medical information computer applications, PowerPoint, word processing and electronic spreadsheets. Ability to identify problems and recommend solutions. Extensive knowledge of federal, state, and payer-specific regulations and policies pertaining to documentation and coding. Extensive knowledge of treatment methodology, patient care assessment, data collection techniques and coding classification systems is necessary. Serve as a resource on DRG issues.