Remote Clinical Documentation Improvement Specialist (CDIS)

The Remote Clinical Documentation Improvement Specialist (CDIS) implements clinical documentation improvement (CDI) activities in an effort to support accuracy and quality of the patient records at CHS facilities and to ensure that coded diagnoses are an accurate reflection of the patient’s clinical status and care.

Community Health Systems is one of the nation’s leading healthcare providers. Developing and operating healthcare delivery systems in 47 distinct markets across 16 states, CHS is committed to helping people get well and live healthier. CHS operates 79 acute-care hospitals and more than 1,000 other sites of care, including physician practices, urgent care centers, freestanding emergency departments, occupational medicine clinics, imaging centers, cancer centers and ambulatory surgery centers.

Summary:
The Remote Clinical Documentation Improvement Specialist (CDIS) implements clinical documentation improvement (CDI) activities in an effort to support accuracy and quality of the patient records at CHS facilities and to ensure that coded diagnoses are an accurate reflection of the patient’s clinical status and care. The CDI specialist reviews the medical record documentation, identifies clinical indicators and works with providers to ensure a complete and accurate medical record. An accurate medical record is important for the patient, to ensure continuity of care by the next provider, and to demonstrate high quality care by the physician and the hospital. The CDI Specialist will identify potential gaps in clinical documentation for assigned populations as directed throughout the hospitalization or encounter. He/she will educate physicians and key healthcare providers regarding clinical documentation improvement and the need for accurate and complete documentation in the health record

The responsibilities include, but are not limited to:

• Performance of medical record reviews
• Issuance of compliant, CHS-approved, best-practice physician documentation clarification requests
• Tracking and reporting of CDIS activities
• Development and delivery of Physician, care team, Coder and Clinical Documentation Improvement Specialist (CDIS) education through a variety of modalities
• Preparation of reports related to CDI activities and outcomes
• Attendance at WebEx or teleconference meetings and/or education sessions as necessary

This individual will possess a broad knowledge of documentation requirements for accurate ICD-10-CM/PCS, MS-DRG, and APR-DRG assignment as well quality data. Adherence to official coding compliance regulations, corporate policies developed to ensure accurate billing and industry best-practice is essential.

Essential Duties and Responsibilities:

• Ensures improved documentation to support appropriate coding, reimbursement and quality data.
• Develops and presents basic, intermediate and advanced education for CHS personnel as follows:
  
  • DRGs and the IPPS
  • Clinical documentation improvement/CDI goals and activities
  • CDI program education and query practices
• Works with hospital or corporate physician liaisons to improve physicians’ understanding of documentation needs for inpatient care.
• Provides documentation/coding education as necessary.
• Possesses an excellent understanding of coding practices, official coding guidelines and federal regulations.
• Keeps abreast of regulatory changes related to inpatient coding and documentation, and communicates these changes to appropriate corporate and hospital staff.
• Maintains a broad knowledge of the clinical aspects of diagnoses, treatment, pharmacology and procedures.
• Maintains chart review skills for documentation quality.
• Possesses the ability to develop and present effective education utilizing a variety of media platforms.
• Ability to track and report documentation improvement activities.
• Completes other duties, as assigned.

Qualifications:

Required Education: Bachelor’s degree in Nursing from an accredited school of nursing, college or university (ASN, AAN, ADN, BSN, RN Diploma, MSN or comparable degree)
Preferred Education: Master’s Degree

Required Experience:

• Minimum of two years CDI experience
• Must possess at least five years of acute hospital nursing experience (e.g. medical/surgical unit, intensive care). Experience in Utilization Management/Case Management, Critical Care, patient outcomes/quality management and/or inpatient coding considered a plus.
• ICU/Critical Care experience strongly desired.
• Previous experience working in a clinical documentation improvement department or as a consultant strongly encouraged.
• Minimum of two years auditing experience strongly encouraged.
• This individual must possess a comprehensive knowledge of medical terminology, disease processes and clinical competency.
• Candidate must possess excellent communication (verbal and written), interpersonal, collaboration and relationship-building skills.
• Strong critical thinking skills and ability to integrate knowledge is necessary.
• Prioritization and organizational skills required.
• Must exhibit the ability to educate members of the healthcare team about clinical documentation.
• Individual must demonstrate data quality and integrity skills.
• Experience working with encoder software, clinical documentation improvement software and the electronic medical record is required.

Preferred Experience:

• Prior experience in clinical documentation improvement, ICD coding and MS-DRGs preferred.
• Prior experience educating physicians/providers preferred.

Required License/Registration/Certification: BSN, RN, or comparable clinical degree.
Preferred License/Registration/Certification: RHIT, RHIA, CDIP, CCDS, CCS and/or ICD-10 certification or designation.

Computer Skills Required:

• Strong working knowledge of word processing software, spreadsheet software and reporting software.
• Experience working with encoder software, clinical documentation improvement software and the electronic medical record.

Physical Demands:
In order to successfully perform this job, with or without a reasonable accommodation, the following are outlined below:

• The Employee is required to read, review, prepare and analyze written data and figures, using a PC or similar, and should possess visual acuity.
• The Employee may be required to occasionally climb, push, stand, walk, reach, grasp, kneel, stoop, and/or perform repetitive motions.
• The Employee is not substantially exposed to adverse environmental conditions and; therefore, job functions are typically performed under conditions such as those found within general office or administrative work.