The Clinical Documentation Improvement Specialist (CDIS) is responsible for managing the improvement of the quality and completeness of clinical documentation by concurrent medical record review and provision of feedback from that review to physicians, other clinical disciplines and HIM coding staff. The CDIS facilitates complete, accurate and specific documentation of diagnoses and level of services provided which is utilized for appropriate coding, core measures and severity of illness measures as appropriate.
Essential Functions:
- Through concurrent medical record review, facilitates appropriate clinical documentation that supports accurate diagnosis coding and ensures that the level of service rendered to all patients is documented. Queries physicians on a concurrent basis to clarify documentation in the medial record
- Demonstrates a high level of communication with clinical and administrative staff and effectively communicates with all Hospital practitioners
- Works with concurrent review physicians to develop and conduct ongoing education for medical staff, clinical documentation specialists, coders, nursing and allied health professionals as needed. Works with concurrent review physicians to develop educational material and tools relative to documentation improvement practices for individual practitioners and groups of clinicians presented as handouts, PowerPoint, overheads, etc
- Utilizes software systems to collect, track, and report outcomes. Requires proficiency in abstracting and data entry into all data bases used for clinical documentation. Maintains integrity of data collection. Ensures accurate date entry. Demonstrates competence in navigation of software. Utilizes software as a resource in ensuring accurate documentation
- Participates in the analysis and trending of statistical data for specified patient populations to identify opportunities for improvement. Assist with preparation of clinical documentation monitoring/trending reports for review with physicians and hospital leadership
- Educates members of the patient care team regarding specific documentation needs and reporting and reimbursement issues identified through daily and retrospective documentation reviews and aggregate data analysis
- Attends and participates in NW and Regional meetings and conference calls. Maintains knowledge and currency with coding practice, regulatory standards and documentation improvement practices
- Other duties as assigned
Qualifications:
Basic Qualifications:
- Minimum of 5 years clinical experience (i.e. Inpatient, clinical documentation, discharge planning, or case management) in an acute care setting
- Current licensure to practice as a Registered Nurse (RN)
- Knowledge of Medicare Advantage and MS-DRG
- Strong interpersonal, communication (verbal, non-verbal, and listening skills)
- Demonstrated ability to conduct and interpret quantitative /qualitative analysis
- Must exhibit efficiency, collaboration, candor, openness, and results orientation
- Understand Adult Learning Theory
- Competent computer skills including work processing, spreadsheets, and presentation software
Preferred Qualifications:
- Graduate from an accredited school of nursing (BSN)
- Clinical Documentation Improvement Specialist (CDIS), Certified Coding Specialist (CCS) or Certified Professional Coder (CPC)
- Strong knowledge and understanding of patho-physiology, disease process and clinical documentation
- Case management / Utilization review experience
- Clinical Documentation Specialist Hospital experience
- Proven leadership skills in project management and consulting
- Demonstrates an understanding of the operations and /or business or Kaiser Permanente, health policy trends and any applicable regulatory requirements related to the responsible practice area
External hires must pass a background check/drug screen.
We are proud to be an equal opportunity/affirmative action employer.