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Senior Clinical Documentation Improvement (CDI) Specialist

Remote:

Full Remote

Experience:

Senior (5-10 years)

Work from:

Panama, Pennsylvania (USA), United States

Offer summary

Qualifications:

3 years clinical acute care nursing experience or equivalent licensing/certification, 5 years as a Clinical Documentation Improvement Specialist.

Key responsabilities:

Evaluate and improve clinical documentation
Educate and mentor staff on documentation standards

UPMC XLarge https://www.upmc.com/

10001 Employees

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Job description

UPMC Corporate Revenue Cycle is looking to hire several Senior Clinical Documentation Improvement Specialists to join our Coding Department. 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 plansBe 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 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.
Plus 5 years of experience working as a Clinical Documentation Improvement Specialist.
Prior CDI work experience preferred.
Knowledge of computer technology, quality assurance activities, DRG, 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.

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)
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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

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