RN - Clinical Documentation Integrity Specialist - Full Time

Job Description

Applicants must reside in Connecticut, Massachusetts, or New York, or willing to relocate.

Reporting to the Manager of CDI, this individual is responsible to identify physician documentation improvement opportunities, ensuring all relevant information is included and accurately reflects the patient’s condition and care. Works closely with physicians and other healthcare providers to clarify documentation and address any discrepancies and / or ambiguities. Participates in continuous close collaboration with the hospital Inpatient Coding team and other on related workflows. Remains current with the latest coding guidelines and documentation standards. Supports the overall success of the CDI program.

Responsibilities

• Provides review of medical records to facilitate appropriate physician documentation of clinical conditions and procedures. -20%
• Analyze medical records to support appropriate severity of illness, expected risk of mortality, complexity of care for the patient, Present on Admission indicator(s), quality measures (Hospital Acquired Conditions, Patient Safety Indicators, etc.), and other focus areas as needed and where applicable. -20%
• Maintains knowledge of ICD-10 diagnosis and PCS procedure coding, MS and APRDRG assignments, clinical conditions, and documentation practices. -5%
• Educates members of the patient care team regarding documentation guidelines, including physicians and extenders, and clinical service areas when appropriate. -10%
• Helps ensure timeliness of all written and verbal queries from providers to ensure proper documentation is obtained and placed in the medical record prior to the patient’s discharge, and post discharge if requested by the Inpatient Coding team. -20%
• Maintains communication with providers as necessary to help ensure timely, complete and accurate medical record documentation. -5%
• Communicates with coworkers in an open and respectful manner that promotes knowledge sharing and teamwork by way of electronic messaging, video and telephone conferencing and in person as needed. -5%
• Follows the United States Department of Health and Human Services (USDHHS) ICD-10-CM Official Guidelines for Coding and Reporting. -5%
• Follows standards of ethical coding and coding interpretive guidelines set forth by AHIMA, ACDIS and the AHA Coding Clinic and other regulatory references as applicable. -5%
• Performs other job-related duties as assigned.

Qualifications

Education and / or Experience Required :

Education and / or Experience Preferred :

License and / or Certification Required :

License and / or Certification Preferred :

Knowledge, Skills and Abilities :

Knowledge :

Skills :

Abilities :

About Us

Connecticut Children’s is the only health system in Connecticut that is 100% dedicated to children. Established on a legacy that spans more than 100 years, Connecticut Children’s offers personalized medical care in more than 30 pediatric specialties across Connecticut and in two other states. Our transformational growth establishes us as a destination for specialized medicine and enables us to reach more children in locations that are closer to home. Our breakthrough research, superior education and training, innovative community partnerships, and commitment to diversity, equity and inclusion provide a welcoming and inspiring environment for our patients, families and team members.

At Connecticut Children’s, treating children isn’t just our job – it’s our passion. As a leading children’s health system experiencing steady growth, we’re excited to expand our team with exceptional team members who share our vision of transforming children’s health and well-being as one team.