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Job Title:

Clinical Documentation Specialist Coordinator

Cost Center:

Health Information Management

Job Description:

The Clinical Documentation Specialist Coordinator (CDI) is responsible for facilitating the improvement in the overall quality and completeness of provider-based clinical documentation in the medical record. This position will be responsible for assisting treating providers to ensure that documentation in the medical record accurately reflects the severity of illness of the patient as well as the level of services rendered. The CDI Specialist assesses clinical documentation through extensive review of the medical record, interaction with physicians, nursing staff, other patient care givers, and Health Information Management (HIM) coding staff to ensure that the clinical information utilized in profiling and reporting outcomes is complete and accurate and appropriate reimbursement is received for the level of services rendered to patients.

Minimum Qualifications

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Education

Graduation from an accredited program of nursing.

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Credentials

Must possess a current, valid RN license in state of practice, temporary RN license in state of practice, or compact RN licensure for current state of practice. CDI certification from professional association required.

Work Environment

Office setting with standard office desks and/or cubicles. Continuous use of computer, photocopy machine, and microfilm reader/printer. Works with very frequent interruptions.

Physical Demands

Stand and/or walk occasionally.

Sit up to six hours per day.

Lift and/or carry up to 10 pounds daily.

Bend and reach throughout the day.

Visual acuity, manual dexterity and hearing within normal limits.

Essential Functions

1. Facilitates appropriate clinical documentation to support appropriate diagnosis coding and to ensure the level of service rendered to all patients recorded.

2. Collaborates with HIM coding staff to promote complete and accurate clinical documentation and correct negative trends.

3. Communicates with physicians, nurse practitioners, case managers, coders, and other members of the care team to facilitate comprehensive medical record documentation to reflect treatment, decision-making and medical documentation.

4. Assigns a working DRG and severity level using coding rules and guidelines with follow-up reviews as required by LOS standards.

5. Analyze clinical information to identify areas within the chart for potential gaps in physician documentation.

6. Queries physicians on a concurrent basis. Works with physicians to clarify documentation in the medical record.

7. Formulate credible clinical documentation clarifications to improve clinical documentation of principal diagnosis, co-morbidities, present on admission (POA), quality core measures, and patient safety indicators (PSI).

8. Conducts post discharge reviews for comparative analysis of CDI Specialist and HIM DRG and severity level assignment. Reviews clinical issues with the coding staff to assign a working DRG and queries physician retrospectively as needed.

9. Utilizes software systems (3M) to collect, track, and report outcomes to MRUR committee. Requires proficiency in abstracting and data entry into all databases used for clinical documentation. Maintains integrity of data collection.

10. Participates in ongoing education of providers by regularly attending hospitalist POC meetings.

Join us. Join great. Join the dynamic team at Great Plains Health and be a part of something truly exceptional. At Great Plains Health, we embody a culture defined by authenticity, integrity, and a genuine commitment to listening to both our patients and each other.

As a member of our team, you’ll experience a supportive environment where collaboration is key, and every voice is valued. We work together seamlessly, leveraging our collective strengths to provide the highest quality care to our community.

Passion drives us forward, propelling us to constantly strive for excellence in everything we do. If you’re seeking a rewarding career in healthcare surrounded by like-minded individuals who share your dedication and enthusiasm, Great Plains Health is the place for you. Come join us and be part of a team that’s making a real difference every day.

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