Clinical Documentation Improvement Specialist (Healthcare)

Job Summary:

• As a Clinical Documentation Improvement Specialist, you will be responsible for improving the overall quality and completeness of clinical documentation by expediting clarification to clinical documentation. This is accomplished through ongoing interactions with physicians and other clinical staff to facilitate the medical documentation in the patient medical record accurately and completely reflects the quality of care rendered to the patient. The accurate and complete medical record documentation will ensure that appropriate reimbursement is received for the level of service rendered to all patients and that information used for measuring and reporting physician and hospital outcomes is correct. This position facilitates improvement of clinical documentation in the medical record to ensure an accurate level of clinical services, appropriate coding of principal and secondary diagnoses, complications, and POA indicators that drive reimbursement, quality performance metrics, CMI, and reduce clinical denials.

 Education: 

• High schools diploma or equivalent education

Licenses and Certifications:

• Must complete and maintain LA City Fire Card certification at the time of hire or within the first 30 days of employment.
• If RN, NP, or Foreign Medical Graduate, Emergency Department or Intensive Care Unit experience with ICD-10 training is strongly preferred.
• California Licensed Registered Nurse, Nurse Practitioner, Physician Assistant, MD graduate/educated in a foreign country, RHIA, RHIT, or CCS.
• CCDS and/or CDIP strongly preferred. 

Experience:

• ICD-10 coding and CDI training.
• One year or more CDI experience or two years or more of inpatient coding experience.

Responsibilities:

• Develop and implement educational programs for nursing staff, including orientation programs, continuing education, and professional development courses.
• Collaborate with clinical leadership to identify learning needs and design appropriate educational materials and programs.
• Conduct training sessions and workshops for nursing staff, both in a classroom setting and through hands-on training.
• Evaluate the effectiveness of educational programs and make improvements, as necessary.
• Serve as a resource and mentor to nursing staff, providing guidance and support in their professional development.
• Stay up to date with the latest advancements and best practices in nursing education and incorporate them into educational programs.
• Collaborate with external organizations and educational institutions to provide additional resources and opportunities for nursing staff. 

Specific Responsibilities:

• Complies with hospital, department, and unit standards, including but not limited to safety, infection control, quality management, environmental, confidentiality, and patient care.
• Prioritizes work and provides prompt and efficient service.
• Improves the overall quality and completeness of clinical documentation by performing admission/continued stay reviews using clinical documentation guidelines.
• Performs review of medical records to identify documentation opportunities to accurately represent the severity of illness, risk of mortality, length of stay, and intensity of service.
• Educates all internal customers, including physicians, on clinical documentation opportunities, coding and reimbursement issues, and quality and medical necessity documentation compliance.
• Assists medical and other patient care staff to identify the most accurate principal diagnosis and secondary diagnoses and chief complaint to accurately reflect severity of illness and risk of mortality in compliance with applicable payer requirements and government regulations.
• Confers with physicians to clarify information, obtain needed documentation, and present education regarding the significance of appropriate documentation needed to support clinical severity and accurate coding.
• Conducts follow-up concurrent and retrospective medical record reviews to ensure that agreed-upon information has been included in medical record documentation.
• Confers with coding specialists and clinicians to ensure appropriate reimbursement for the level of service rendered to all patients with DRG-based payers. Ensures the clinical information utilized in profiling and reporting outcomes is complete and accurate.
• Demonstrates competency in selected administrative skills, including but not limited to:
• Performs chart and/or data abstract reviews.
• Conducts concurrent review of CMS/DNV measures and optimum DRG documentation.
• Working knowledge of ICD-10, MS-DRG, APR-DRG coding assignment, HACs, CCs, and MCCs as required.
• Familiarity with CPT and HCPCS preferred.
• Knowledge of Inpatient Prospective Payment System (IPPS) documentation requirements for proper APR & MS DRG assignment.
• Interfaces with physicians for documentation clarification.
• Enters results of concurrent and retrospective reviews in a computerized tracking and reporting system.
• Edits, compiles, and assists in analyzing data for studies, audits, and other reports.
• Assists in training new personnel.
• Assists with care and maintenance of department equipment and supplies.
• Maintains department records, reports, and files as required.
• Demonstrates responsibility and accountability for own performance on the team.
• Attendance and punctuality.
• Positive public relations image and working relationships.
• Obtaining the necessary knowledge and skills needed to maintain competence.
• Completing all mandatory requirements.
• Participates in the development and attainment of team, department, and hospital goals including:
• Attending and participating in team meetings.
• Volunteering or accepting assignments for projects.
• Mission, vision, and team ground rules.
• Performs other related duties as assigned or requested.
• Educates all internal customers, including physicians, on clinical documentation opportunities, clinical denials coding, reimbursement issues, and DNV/CMS measure compliance.
• Assists with denial management and prevention as it relates to documentation.
• Formulates credible clinical denial appeals.
• Assists physicians and other caregivers in the identification of the most appropriate principal diagnosis and chief complaint to accurately reflect the severity of illness in compliance with applicable payer requirements and government regulations.
• Confers with physicians to clarify information, obtain needed documentation, and present education regarding the significance of appropriate documentation needed to support clinical severity, accurate coding, and DNV/CMS measure compliance. 

Key Responsibilities:

• Patient Care Excellence: Champion a positive patient experience, ensuring high standards of care and safety.
• Team Leadership: Mentor and support staff, fostering a collaborative and efficient work environment.
• Operational Management: Oversee scheduling, resource availability, and staff assignments to ensure smooth operations.
• Communication & Collaboration: Facilitate clear communication between patients, families, staff, and physicians.
• Performance Improvement: Participate in quality initiatives and ensure compliance with regulatory requirements. 

 Salary Range: $49.25 - $64.52 per hour