Job Description

The Clinical Documentation Specialist Senior is responsible for facilitating the improvement in the overall quality and completeness of provider-based clinical documentation in the medical record by working directly with providers. This position is responsible for assisting treating providers to ensure that documentation in the medical record accurately reflects the severity of illness, risk of mortality, complexity of patient care, and hierarchal condition categories of the patient. This position will recognize opportunities for documentation improvement and hold collaborative discussions with providers. The Senior level is expected to function as a subject matter expert on the team and assist less experience team members in understanding and following operational policies. This role is responsible for training and onboarding new team members and participating in special projects assigned by the Mid Revenue Cycle leadership.

The Clinical Documentation Specialist (CDI) Senior assesses clinical documentation through extensive medical record review and utilization of clinical judgment, deployment of artificial intelligence, and collaborating directly with the providers to clarify the documentation to accurately and completely reflect the patients’ medical conditions. This position conducts independent research to ensure compliance when developing provider queries, while interpreting and applying evolving standards from governing bodies AHIMA and ACDIS and maintaining up-to-date knowledge of coding changes and updates released each April and October.

Extensive collaboration with physicians, mid-levels, nursing staff, other patient care givers to include developing and delivering education, which will be accomplished with zoom meetings, telephonic discussions, and email.

Additionally, the Clinical Documentation Specialist Senior (CDI) will collaborate with the Health Information Management (HIM) coding staff and the Educators to ensure that appropriate reimbursement is received for the level of services rendered to patients, clinical information utilized in profiling and reporting outcomes is complete and accurate.

Responsibilities:

• Reviews medical records for quality, completeness, and accuracy of documentation. Ensures that coded diagnoses accurately reflect level of patient care and patient status, including severity of illness and risk of mortality. Identifies gaps in documentation as well as conflicting or unspecified diagnoses and clarifies diagnoses with providers to assign the most accurate ICD 10CM/PCS code from the documentation. Must meet and maintain the quality and productivity measures established per polices.
• Delivers ongoing education to providers through collaboration and communication via on-site meetings, zoom meetings, telephonic discussions, rounding, and email. Provides supplemental educational material and tools relative to documentation improvement practices for individual practitioners and groups of clinicians.
• Identify and share documentation improvement opportunities with providers to capture the patient's accurate severity of illness and risk of mortality, comorbid conditions, and all other condition categories.
• Develop clear, concise and compliant written and verbal queries to providers, seeking clarification on unclear, incomplete, or non specified documentation. Utilizes software system and the Natural Language Processor (NLP) to review, compile clinical indicators for provider collaboration, code, collect, track, and report outcomes accurately and timely.
• Key Performance Indicators and additional significant metrics will be reported and discussed regularly, and as needed to the Medical Executive Committee via presentation to the Medical Records Committee and with other committees as directed
• The Senior is expected to function as a subject matter expert on the team and assist less experience team members on following operational policies. It is responsible for training and onboarding new team members and participating in special projects assigned by the Mid Revenue Cycle leadership.

Credentials and Experience:

• Associate’s Degree – field of study: Nursing, HIM or another Healthcare related field
• A minimum six (6) years' acute care clinical documentation experience to include:
  • Applying Medicare, Medicaid and Commercial payer regulations, charging and coding guidelines
  • Healthcare regulations
  • ICD-10-CM, ICD-10-PCS coding
  • Performing independent queriesER

Certifications:

• (CCDS) Certified Clinical Documentation Specialists from ACDIS
• (CDIP) Certified Documentation Integrity Practitioner from AHIMA
• (CDEI) Certified Documentation Expert Inpatient from AAPC
• Registered Nurse (RN) *in lieu of a certification listed above, an (active) RN will satisfy the certification requirement

Minimum Skills/Specialized Training Required

• Proven record of combining clinical knowledge and coding skills.
• Ability to recognize opportunities for documentation improvement and hold collaborative discussions with providers to address the opportunities in documentation.
• Proficient in computer skills including MS Office, Optum 360 eCAC, Cerner EHR.
• Organized, analytical, superior interpersonal and writing skills.
• Dependable, self-directed with critical thinking, problem solving, and deductive reasoning.
• Knowledge of healthcare regulatory environment.
• Understand and support clinical documentation management strategies.
• Must be flexible to accommodate clinician schedules.
• Knowledge of Case Mix Index and how it is influenced.

Preferred Experience

• 4 years' experience in oncology.
• Vizient experience.

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