CDI - Clinical Documentation Improvement Specialist

Primary responsibility is to facilitate improvement in the overall quality, completeness, and accuracy of clinical documentation.  Through concurrent interaction with physicians, nurses, case managers, coders and other health care team members, the Clinical Documentation Analyst (CDA), will strive to ensure comprehensive medical record documentation that reflects the clinical treatment, decisions, and diagnosis for all Medicare inpatients.  Serving as a resource to all members of the health care team on documentation guidelines, this position will provide guidance and support, as well as assisting with education and training related to improving clinical documentation.  This position will actively participate in educating appropriate hospital and medical staff about ICD-10.

• Conducts daily reviews of inpatient medical records either in the nursing unit and/or on the computer to identify missing, vague, and/or incomplete diagnoses and procedures
• Conducts timely follow-up reviews of clinical documentation to ensure that issues discussed and queries left in the medical record have been answered by the provider
• Utilizes coding and clinical expertise to identify opportunities and ensure the accuracy and completeness of clinical documentation for measuring and reporting physician and hospital outcomes
• Queries physicians on specificity of procedures performed and diagnosis based on accepted coding guidelines, clinical expertise and LifePoint Hospitals policy
• Tracks and trends specific opportunities for improvement through the query process utilizing approved metrics reporting
• Conducts educational sessions with physicians and other health care team members on documentation requirements
• Conducts CDI on-boarding education of all new admitting physicians as part of the hospitals orientation program
• Reviews clinical issues and identified query response concerns with physician advisors
• Participates in data collection to document findings and outcomes to drive quality improvement and improved clinical documentation
• Stays current with requirements of CMS Inpatient Prospective Payment Systems (IPPS), AHA Coding Clinic and Official Guidelines for Coding and Reporting related to ICD-10
• Participates in department and facility Quality and Performance initiatives
• Works closely with nursing, case management, quality, risk management, and medical staff credentialing to provide data related to key clinical indicators and operational metrics
• Works in conjunction with the Director of Quality, Medical Staff Credentialing and medical staff leadership to assure effective monitoring and successful completion of identified plans for improvement
• Prepares and presents educational programs to all internal constituents related to clinical documentation issues and coordinates same with clinical staff, physicians, compliance and coding staff
• Makes regular reports of progress toward goals associated with clinical documentation improvement opportunities and operational improvement plans
• Establishes cooperative working relationship with diverse groups and individuals, medical staff and other health care disciplines and interact with all levels of employees
• Develops and maintains a professional working relationship with medical staff, clinical staff, medical records and business office staff
• Maintains a knowledge base of the characteristics of disease, illness, disabling conditions that directly impact the patient’s state of physical or mental health
• Collaborates, coordinates and consults with members of the healthcare team to facilitate appropriate documentation in the medical record for concurrent chart abstraction and coding
• Understands the legal and ethical issues pertaining to confidentially as well as liability issues for coding activities
• Attends meetings as required and participates on committees and teams as directed