Certified Clinical Documentation Integrity Specialist Lead

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The information described in this job description has been designed to indicate the general nature of the work performed. It is not designed to contain or be interpreted as a comprehensive inventory of all duties, responsibilities and qualifications required of employees assigned to this job.

Other information : Job Summary

The information described in this job description has been designed to indicate the general nature of the work performed. It is not designed to contain or be interpreted as a comprehensive inventory of all duties, responsibilities and qualifications required of employees assigned to this job. The Clinical Documentation Integrity Specialist facilitates improvement in the overall quality and completeness of clinical documentation. Obtains appropriate clinical documentation through extensive interaction with physicians, nursing staff, other patient caregivers, Care Management and Health Information Management. Collects and analyzes data to provide reports and make recommendations for improvement.

Essential Functions

Performs concurrent reviews for inpatient hospital encounters. Assists coders with retrospective and concurrent reviews. Performs follow-up with Providers on discrepancies and requests for additional documentation as needed. Regularly shares program performance data with provider groups. Captures and presents physician dashboard data to compliance committee, MEC, executive leadership and board upon request. Collaborates with RN Case Managers around medical necessity and level of care concerns. Coordinates with inpatient coding staff on diagnosis code and ICD-10 transitioning. Contributes to template efforts. Reviews chart and abstracts data to pre-code prior to final coding. Provides training to other staff as needed. Maintains current knowledge of clinical documentation national standards, benchmarks, ICD -10CM / PCS and government regulations through self-audit, RAC review and continuing education opportunities. Maintains department specific new employee orientation program. Executes quality improvement initiatives and tracking outcomes. Manages the CDI Team work schedule while allocating team and individual assignments. Ensures provider education and data collection exercises occur as expected. Facilitates meetings, records meeting minutes and tracks related action items. Validates that team is meeting continuing education requirements. Complies with all SRH policies and procedures. Performs other duties as assigned.

Education

BSN or Bachelor Degree in related healthcare degree required.

Experience / Training

Minimum five (5) years clinical RN experience in Med / Surg / CCU or ER. Previous CDI experience required.

License / Certifications

Current and unrestricted Washington State RN license required. Must hold and maintain the designation of either Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Integrity Practitioner (CDIP).

Other Skills

Effective written, verbal and interpersonal communication skills. Ability to analyze data for patterns and trends. Strong critical thinking skills and ability to integrate knowledge. Ability to prioritize work-load amongst frequent interruptions and competing priorities. Knowledge of ICD-9 and ICD-10 coding guidelines. Knowledge of Medicare inpatient guidelines. Ability to understand and interpret clinical data to appropriately allocate diagnoses leading to an accurate and compliant DRG. Strong computer skills with knowledge of Microsoft Office and electronic medical record. Ability to speak comfortably in front of a group.

Physical Demands and Work Environment

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. While performing the duties of this job, the employee is regularly required to talk and hear. Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception and ability to focus. This position involves repetitive tasks such as typing, sitting, answering phones, and interacting with computers and computer systems, and also requires standing and walking for extended periods.Skagit Regional Health offers a comprehensive benefit package including medical, dental, vision, 457b / 401a (retirement), long term disability, and paid time off to all employees holding an FTE of 20 or more hours per week. Eligible employees also receive sick time pay.