CDI Specialist - RN2
 Newton-Wellesley Hospital | |
 United States, Massachusetts, Newton | |
| 2014 Washington Street (Show on map) | |
 Jan 21, 2025 | |
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Under the general direction of the Manager, the Clinical Documentation Specialist facilitates improvement in the overall quality, completeness, and accuracy of medical record documentation for the purposes of ensuring compliance with Medicare and Medicaid (CMS) regulations and guidelines and to expedite appropriate reimbursement. Utilizes both clinical and coding knowledge to obtain appropriate documentation through extensive interaction with physicians and Health Information Management staff. Educates all members of the patient care team regarding documentation guidelines on an ongoing basis. Helps to assure case mix index, DRG assignment and severity/mortality profiles are accurate.
Sensory Requirements: Visual Activity - consistent close paperwork (paperwork, forms, data entry, data collection, etc.), consistent monitor-CRT, consistent visual monototy, and frequent color vision required. Auditory Activity - consistent conversation, telephone, and background noise. Frequent monitoring equipment and transcription. Sensory Discrimination - Hot/Cold, and Sharp/Dull. Does this position require Patient Care? Yes Essential Functions -Carries out concurrent medical record reviews for identified payer populations as directed on admission and throughout hospitalization and for clinical documentation improvement opportunities in the acute care setting. -Reviews physician documentation related to the current treatment plan and past medical history and identifies documentation gaps /opportunities on a daily basis and /or as needed. -Ensures that the clinical documentation is complete, accurate and compliant with the Center for Medicare and Medicaid Services regulations and that it reflects the level of service rendered. -Assists in the development of diagnosis/DRG specific queries to assist physicians with documentation. -Serves as a resource for physicians to help link ICD-9 and 10 CM coding guidelines and medical terminology to improve accuracy of patient severity of illness, risk of mortality and final code assignment. -Resolves inconsistent, conflicting and/or ambiguous documentation through the query process. (The query process serves as ongoing education and requires specific clinical indications and treatment plans for appropriate coding and reimbursement.) -Assigns a working DRG based on coding guidelines/regulations issued by AHA (Coding Clinic), CMS, and AHIMA. -Interprets clinical information in medical record, evaluates medications, vital signs, surgical outcomes, etc. to identify potential diagnoses. -Identifies physician documentation issues/omissions/discrepancies and communicates with physicians in person, via the telephone, e-mail and/or through written physician queries about opportunities for more accurate documentation to achieve department standards for acceptable physician response rates. -Helps to ensure documentation reflects the patient's past medical history, acuity and intensity of services provided. -Collaborates with HIM coding, Care Coordination, Quality staff, physicians, and patient accounts regarding coding deficiencies and/or denials that may be attributed to documentation issues. -Utilizes the 3M grouping software to determine the working DRG and communicate with the HIM coding staff. -Monitors and evaluates the effectiveness of concurrent chart review and query outcomes at designated intervals in collaboration with manager and coding staff. -Enters data into a designated software program for CDI that is reviewed by coding staff to facilitate ongoing feedback to the Clinical Documentation Improvement (CDI) team. -Possesses conflict management skills and has the ability to identify and solve problems and participate in remediation efforts. -Provides prompt and courteous customer service. -Maintains patient confidentiality. -Quality Assessment/Performance Improvement *Identifies quality of care issues; analyzes, documents, and reports appropriately in accordance with Hospital and departmental policies and procedures, including but not limited to generic and specific occurrence screening, patient incidents, adverse drug reactions, and risk management issues. *Conducts QA/PI activities as directed *Provides reports/findings to medical staff and /or other hospital committees. *Assists with data collection and analysis as necessary. -Professional development *Maintains professional competency by keeping abreast of new coding issues and guidelines, attending applicable educational programs and meetings, and reviewing professional coding literature. *Participates in seminars, in-service/educational efforts and activities sponsored by professional associations at the local, state, and national levels. *Seeks voluntary membership with a national CDI group such as ACDIS and participates in the resources including conference calls, blogs, newsletter, etc. Education Experience This role requires a minimum of 3-5 years of clinical documentation/coding experience required Newton-Wellesley Hospital is an Equal Opportunity Employer. By embracing diverse skills, perspectives and ideas, we choose to lead. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and/or other status protected under law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment. | |