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*Applicants must meet the minimum qualifications for the position as stated in the job posting.
*Applicants must submit an additional application for each individual posting in which they are interested and qualified to perform.
RN - Clinical Documentation Integrity Specialist Facility: OSF St. Joseph Medical Center
Bloomington IL, 61701
Department: Clinical Documentation Integrity Schedule: full-time Shift: Day Hours: Hours Per Pay Period: 80 Referral Bonus: Contact Information:
- Contact: Sarah Gillette
The CDI specialist is a resource for improving the overall quality, integrity and completeness of clinical documentation. The position will facilitate the completion of documentation by physicians, allied health professionals, nurses and other patient care givers that accurately reflect the severity of illness, risk of mortality and treatment given. The CDI specialist conducts concurrent review of medical records to ensure that documentation supports accurate diagnostic and procedural coding and DRG assignment while adhering to documentation guidelines provided by CMS, AMA and other regulatory bodies. The CDI specialist will participate in performance improvement and utilization issues in relation to documentation of patient care. Collaboration with various departments such as Care Management, Utilization Review, Education and Training, Health Information Management, Revenue Cycle, Finance, Compliance, Physician Liaisons, Medical Staff and Administrative Leadership is imperative. The specialist collects and analyzes data relative to the clinical documentation improvement program. This position also insures the accuracy and completeness of clinical information used for measuring and reporting physician and Facility outcomes. The CDI specialist works with all members of the CDI program to educate the patient care team on documentation related issues on an ongoing basis.
1. Completes review of medical record for each assigned patient as defined by departmental policy, in the timeframe and as frequently as required. Identifies the most appropriate principal diagnosis; comorbidities and complications and other diagnosis to accurately reflect the severity of illness, procedures and treatments.
2. Identifies secondary diagnoses that are present at admission for accurate assignment of the POA indicator.
3. Identifies clinical documentation needed to support the principal diagnosis, secondary diagnoses, severity of illness, plan of care, and assignment of appropriate DRG.
4.Follows established procedures, according to AHIMA/ACDIS guidelines, to query providers on documentation that is ambiguous, inconsistent or needs specification. Works with these care givers to assure they understand the need to clarify the documentation.
5. Communicates with physicians via clinical documentation query forms to clarify information and obtain needed clinical documentation. Presents opportunities based on current and reliable clinical indicators and educates for appropriate DRG based on severity of illness and complexity of care of the patient.
6. Conducts follow-up reviews of clinical documentation to ensure points of clarification have been recorded in patient’s chart.
7. Collaborates with HIM, case managers, nursing staff, and other ancillary staff regarding interaction with providers on documentation and to resolve provider queries prior to patient discharge.
8. Reports findings related to clinical documentation improvement program.
9. Confers with Physician Liaison as needed.
10. Collects and enters data into the tracking data base.
11. Works in a collaborative fashion with the coders in concurrently reviewing the inpatient medical record to assure correct provisional and final DRG assignment.
12. Assist the coders in facilitation of the physician query process.
13. Attends mandatory department meetings, in services, and appropriate work-related educational programs.
14. Develops and maintains a positive working relationship with Patient Care Team members, department, facility personnel, patients and visitors.
15. Maintain accurate records of review activities to comply with departmental and regulatory agency guidelines.
16. Collaborates with ministry wide and facility compliance guidelines.
17. Serves as a resource to department managers, staff, physicians and administration to obtain information or clarification on accurate and ethical coding and documentation standards, guidelines and regulatory requirements.
18. Supports and is involved in the facility’s continuous quality improvement efforts designed to increase patient outcomes, increase patient satisfaction, and improve the utilization of the facility’s human, capital and physical resources.
19. Maintains confidentiality of all clinical data.
20. Travels to other OSF facilities, as needed.
21. Assists with projects and general division functions of the Clinical Documentation Program, as needed.
KNOWLEDGE SKILLS AND ABILITIES REQUIRED:
1. RN, BSN preferred, with a minimum of two years recent clinical experience in a hospital setting and/or Bachelor or Associate degree in Health Information Management RHIA, RHIT required, minimum two years inpatient coding experience with ICD-10 coding knowledge preferred. CCS, CCDS, or CDIP certification preferred.
SKILLS AND ABILITIES:
1. Requires excellent observation skills, analytical thinking, problem solving, plus good verbal and written communication skills.
2. Professionalism and the ability to handle confidential information.
3. Flexibility and the willingness to adapt to evolving job roles within the constantly changing work environment is required.
4. Must demonstrate excellent customer service, organizational and listening skills.
5. Self-starting, effective leader with good personal relationship skills and the ability to act upon their own independent thought processes.
6. Ability to work in a collaborative atmosphere.
7. Ability to sense varying skill levels and direct instruction accordingly.
8. Communicates information effectively. Responding to questions, concerns and requests promptly. Encouraging communication by promoting open dialogue.
9. Ability to accept and incorporate critical comment.
10. Capable of critical thinking reasoning, deduction, and inference while displaying the ability to draw accurate conclusions.
11. Must be results oriented, respond to questions with definitive answers, and be able to meet deadlines.
12. Ability to understand corporate management functions and to work effectively in that environment.
13. Actively participates in the OSF HealthCare Committees and other groups, as assigned.
14. High level of analytical ability is necessary, as problems are sometimes complex.
15. Ability to proficiently operate a personal computer and computer software programs necessary to carry out principal duties including Word, Excel, Lotus Notes, and organizational specific systems.
16. Epic software application experience
17. Prior CDI/CAC software application experience
18. AHIMA - CDIP and/or CCS credentialing preferred
19. ACDIS - CCDS credentialing preferred
20. Strong interpersonal, written, and oral communication skills are required.
21. Demonstrated ability to work well with others.
22. Excellent computer skills and the ability to process detailed information in an accurate manner.
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