Clinical Documentation Improvement Specialist

POSITION SUMMARY

POSITION SUMMARY : The Clinical Documentation Improvement (CDI) Specialist 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 the illness of the patient as well as the level of services rendered.

JOB ESSENTIAL DUTIES

JOB ESSENTIAL DUTIES : Facilitates appropriate clinical documentation to support appropriate diagnosis coding and to ensure the level of service rendered to all patients is recorded.

• Review and audit patient charts in the EHR for the clinical status of the patient, current treatment plan, past medical history, quality measures (e.g., HEDIS, HCC, etc.), and identify potential gaps in provider documentation.
• Applies clinical knowledge and expertise to accomplish optimal identification of patient's condition in the medical record.
• Communicates with providers to validate observations for more specific documentation and / or diagnoses via concurrent query process guidelines to reflect treatment, decision-making, and medical documentation. Collaborates with physicians and coding staff to promote complete and accurate clinical documentation and correct negative trends.
• Formulates credible clinical documentation clarifications to improve clinical documentation of principal diagnosis, co-morbidities, and quality core measures.
• Conducts post-visit reviews for comparative analysis of CDI process. Develops and conducts ongoing education for new staff, including new CDI Specialists, physicians, and nursing.
• Ability to work at the Population Health Events during the work week and on some Saturdays. Utilizes software systems (e.g., Athena, ENLI) to collect, track, and report outcomes.
• Abstracts and completes data entry into all databases used for clinical documentation. Maintains integrity of data collection.
• Participates in the ongoing education of staff related to the scope of the role.
• Develops educational material and tools to support documentation improvement practices for individual practitioners and groups of clinicians.
• Maintains an open line of communication with the leadership team on the status of MCR Health operations and key performance indicators as it relates to areas of assigned responsibility. Obtains and maintains any identified certifications.
• Promotes the concept of Providing an Exceptional Experience to Everyone, Every Time.
• Completes day-to-day tasks to assure the smooth operation of MCR Health. Supports the mission and vision of MCR Health.
• Adheres to all MCR Health policies, procedures, and standards.
• Performs other duties as assigned.

SKILLS, KNOWLEDGE & ABILITIES

REQUIREMENTS & PREFERENCES

J-18808-Ljbffr