Clinical Documentation Integrity Specialist

Summary

• Monday-Friday 7:30 AM - 4:00 PM

• GENERAL SUMMARY

• The Clinical Documentation Integrity Specialist is responsible for reviewing inpatient medical records to assess and procure accurate and complete documentation of the patients’ diagnosis and procedures. Reports to department leadership.

• ESSENTIAL DUTIES AND RESPONSIBILITIES

• Reviews Inpatient Clinical Documentation, ensuring that physicians’ and clinicians’ documentation, accurately reflect the patient’s conditions, diagnoses, treatments, and interventions, resulting in accurate reimbursement.

• Reviews to ensure the clinical documentation, reflects the patient’s severity of illness, quality of care and resources used.

• Provides education to the physicians and ancillary providers regarding accurate, specific and compliant clinical documentation.

• Acts as a resource for other departments regarding the importance of clinical documentation integrity, and the need to clinically document following the Federal and State regulations.

• Performs all other duties as assigned.

• LICENSES AND/OR CERTIFICATIONS

• Required Licenses and/or Certifications

• Current Virginia state license as a Registered Nurse or Registered Nurse holding a valid Compact State license required.

• Preferred Licenses and/or Certifications

• Certified Documentation Improvement Professional (CDIP) or Certified Clinical Documentation Specialist (CCDS) certification or must be credentialed through AHIMA or ACDIS, within two years of start preferred.

• MINIMUM EDUCATION AND EXPERIENCE REQUIREMENTS

• Required Education and Experience

• Registered Nurse -Professional knowledge of nursing theory and practice at a level normally acquired through the completion of an accredited School of Nursing.

• Preferred Education and Experience

• BSN preferred.

• Pediatric and or Clinical Documentation or Utilization Management preferred.

• Required Knowledge, Skills and Abilities

• Experience with applying clinical criteria to a medical record review with a Clinical Documentation Integrity focus.

• Knowledge of healthcare payment systems, specifically the MS-DRG, Tricare and APR-DRG reimbursement systems.

• Ability to form positive and collaborative relationships, with Physicians, HIM colleagues, the Physician Advisor and other hospital staff.

• Competent using Microsoft Office Suite, and different Electronic Medical Records.

• Requires Strong organizational, clinical critical thinking and analytical skills.

• Preferred Knowledge, Skills and Abilities

• Technical and professional knowledge and skills for clinical operations of the service area, usually acquired through 3 - 5 years’ progressive Clinical/Supervisory experience in a practice setting.

• WORKING CONDITIONS

• Normal office environment with little exposure to excessive noise, dust, temperature and the like.

• PHYSICAL REQUIREMENTS

• Click here to view physical requirements.