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Senior Clinical Documentation Improvement (CDI) Specialist

Remote: 
Full Remote
Contract: 
Experience: 
Senior (5-10 years)
Work from: 

Offer summary

Qualifications:

3 years acute care nursing experience, Knowledge of DRG and coding, Licenses: RHIA, RHIT, CCS, or similar.

Key responsabilities:

  • Evaluate clinical documentation daily
  • Communicate with physicians on documentation
  • Provide education and mentoring for CDS team
  • Conduct audits to ensure quality standards
  • Participate in CDI improvement initiatives
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Job description

UPMC Corporate Revenue Cycle is hiring a Senior Clinical Documentation Improvement Specialist to join our coding team. This position will be a work-from-home position working Monday through Friday during normal business hours.

The Senior Clinical Documentation Specialist (CDS) facilitates modifications to clinical documentation through concurrent interaction with physicians and other members of the healthcare team to ensure that appropriate clinical severity is captured for the level of services rendered to all inpatients. In this role, you will also support the CDS team through education, mentoring, and other CDI initiatives as needed.

Responsibilities:

  • Provide daily clinical evaluation of the medical record including physician and clinical documentation, lab results, diagnostic information and treatment plans. Be responsible for the day-to-day evaluation of documentation by the Medical Staff and healthcare team. Communicate with physicians, face-to-face or via clinical documentation inquiry forms, regarding missing, unclear or conflicting medical record documentation to clarify the information, obtain needed documentation, present opportunities, and educate for appropriate identification of the severity of illness
  • Demonstrate an understanding of complications, co-morbidities, severity of illness, risk of mortality, case mix, secondary diagnosis, impact of procedures on the final DRG, and an ability to impart this knowledge to physicians and other members of the healthcare team. Preparing trended data for presentation one-on-one and small to medium groups of physicians Participating at the organizational level in clinical documentation improvement initiatives
  • Onboarding and mentoring new CDI Specialist staff. Assist with the one-on-one education with staff identified as having quality or productivity-related deficits based on audits conducted within the department. Conduct audits on staff to ensure quality indicators are met. Review findings with appropriate personnel. Provide education-related sessions on CDI topics during staff meetings or through email communication at least twice per year. Perform CDI-related work duties in accordance with established quality and productivity standards (i.e., work CDI patient list and markers regularly to ensure work production requirements are met).*Performs in accordance with system-wide competencies/behaviors.*Performs other duties as assigned.
  • Three years of previous clinical acute care nursing experience medical/surgical experience to include critical care in conjunction with an expanded knowledge of DRG's; OR completion of Health Records Administration program (RHIA) or Accredited Record Technician (RHIT) OR Certified Coding Specialist (CCS) AND 3 years of experience with the Prospective Payment System and DRG selection; OR specific knowledge as a consultant in Medical Record coding and DRG assignment required.
  • Knowledge of computer technology, quality assurance activities, DRG, and Quality Insights/Utilization review background is highly preferred. Ability to communicate with staff, physicians, healthcare providers, and other healthcare system personnel in a professional and diplomatic manner required.
  • Plus 5 years experience working as a Clinical Documentation Improvement Specialist.

Licensure, Certifications, and Clearances:

  • Employees practicing in Maryland: Respiratory Therapist license may be used in substitution of the aforementioned certifications and licensure.
  • Certified Clinical Documentation Specialist OR Certified Coding Specialist (CCS) OR Certified Registered Nurse Practitioner OR Doctor of Medicine (MD) OR Doctor of Podiatric Medicine OR Registered Health Information Administrator OR Registered Health Information Technician (RHIT) OR Registered Nurse (RN)
  • Current licensure either in the state where the facility is located or, if the facility is in a state covered by the multistate Nursing Licensure Compact (NLC) agreement, a multistate license issued by a participating NLC state. Hires and current employees working on an out-of-state NLC license who later change their residency to the state where the facility is also located will have 60 days upon changing their residency to apply for licensure within that state.

UPMC is an Equal Opportunity Employer/Disability/Veteran

Annual

Required profile

Experience

Level of experience: Senior (5-10 years)
Spoken language(s):
English
Check out the description to know which languages are mandatory.

Other Skills

  • Verbal Communication Skills
  • Training And Development
  • Mentorship
  • Problem Solving
  • Quality Assurance
  • Computer Literacy

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