Key Facts

Remote From:

Full time

Mid-level (2-5 years)

English

Hard Skills

Clinical Data Analysis ICD Coding (ICD-9/ICD-10) Payment Plan Agreements Clinical Documentation Hospital Information Systems Reimbursement Regulations Patient Education And Counseling Diagnosis-Related Group Clinical Auditing Clinical Documentation Clinical Documentation Emergency Departments Hospital Experience Customer Centricity Presentation Training Total Quality Management

Other Skills

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Computer Literacy
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Microsoft Office
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Adaptability
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Analytical Skills
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Multitasking
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Negotiation
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Teamwork
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Organizational Skills
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Detail Oriented
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Verbal Communication Skills
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Social Skills

Roles & Responsibilities

Licensed as a Registered Nurse with an Associate Degree (ADN) or Bachelor's degree in Nursing (BSN), or an MD, with at least three (3) years of recent acute care nursing experience; ICU or ED experience preferred.
HIM professional candidates: Credentialed as an RHIA, RHIT, CPC, or CCS with at least three (3) years of clinical coding and/or auditing experience in a hospital environment; ICD-10 experience.
Strong computer literacy and excellent communication, negotiation, and organizational skills; ability to work both collaboratively and independently; proficiency with MS Office and healthcare information systems.
CDI certifications (CCDS or CDIP) strongly desired; CCS preferred; Meditech Expanse experience preferred; knowledge of ICD-10, DRG and prospective payment methodologies.

Requirements:

Improve the overall quality and completeness of clinical documentation by performing concurrent stay reviews and obtaining appropriate documentation through interactions with physicians, nursing staff, and HIM coding staff to ensure appropriate reimbursement.
Educate internal staff on documentation needs, changes to documentation guidelines, coding and reimbursement issues; conduct follow-up reviews to ensure clarified points are recorded in the patient’s record and assist the team in meeting CDI program metrics.
Utilize Coding Clinic guidelines to enhance documentation quality; track documentation notes, assign Working DRG, calculate Query DRG, enter and validate queries to ensure final coded diagnoses are reflected in the EMR.
Follow established CDI workflows; compose and initiate AHIMA-compliant queries; maintain open communication with coding; participate in routine CDI program activities and stay current with regulations.

Job description

Here at Savista, we enable our clients to navigate the biggest challenges in healthcare: quality clinical care with positive patient experiences and optimal financial results. We partner with healthcare organizations to problem solve and deliver revenue cycle improvement services that enable their success, support their patients, and nurture their communities, all while living our values of Commitment, Authenticity, Respect and Excellence (CARE).

The Clinical Documentation Integrity Specialist (CDIS) is responsible for facilitating the improvement in the overall quality and completeness of medical record documentation. Obtains appropriate clinical documentation through extensive interaction with physicians, nursing staff, other patient care givers, and Health Information Management coding staff to ensure that appropriate reimbursement is received for the level of services rendered to patients and the clinical information utilized in profiling and reporting outcomes is complete and accurate. Meditech Expanse experience preferred.

Position Objectives:

The CDIS will facilitate modifications to clinical documentation, through extensive concurrent chart review, interactions with physicians and other clinicians, in order to ensure accurate documentation of diagnosis and procedures, reflection of appropriate clinical severity, clarification of complications and conflicting documentation, and capture of co-morbid conditions.
The CDIS will complete majority of concurrent reviews to evaluate selected patient's medical records for overall quality and completeness.
Education of physicians, non-physician clinicians, nurses and coding staff on an ongoing basis regarding documentation opportunities, coding and reimbursement issues and relevant quality and performance improvement opportunities.
Assist team in meeting and exceeding high performing CDI program metrics

Essential Duties & Responsibilities:

Utilize extensive knowledge of documentation requirements and guidelines in accordance with Coding Clinic to improve the overall quality and completeness of clinical documentation by performing concurrent stay reviews.
Utilize client technology to track documentation notes and observations, assign Working DRG and calculate Query DRG to reflect impact of queries initiated, complete query entry for tracking purposes and complete validation process to ensure diagnosis located in EMR or attained by query are final coded
Educate internal staff on clinical documentation needs, changes to clinical documentation guidelines, coding and reimbursement issues and conduct follow up reviews of clinical documentation to ensure points clarified with the physician have been recorded in the patient’s record.
Follow establish workflows and processes developed for Clinical Documentation Integrity, Strategic Source
Compose and initiate AHIMA compliant queries.

Internal Responsibilities:

Utilize client CDI technology and follow established standardized process flow
Maintain open communication with coding to discuss DRG assignment, diagnosis, clinical indicators, coding clinics and guidelines and educating each other on specialty.
Assign Working DRG for Case Management department to view Length of Stay (LOS) of patients.
Participate and provide input regarding CDI program activities, and attendance at routine team meetings.
Maintain current skill set with regard to government regulations, compliance and reimbursement guidelines.
Expected to keep abreast of new legislation and regulations that affect CDI.
Maintain personal and professional education and growth.
Responsible for maintaining continuing education credits as required by credentialing organization.

Minimum Qualifications & Competencies:

Clinical candidates: Licensed as a Registered Nurse with an Associate Degree (ADN) or Bachelor’s degree in Nursing (BSN), or an MD
At least three (3) years of recent acute care nursing experience required. ICU or ED experience preferred. Clinical expertise required.
HIM professional candidates: Credentialed as an RHIA, RHIT, CPC, or CCS and have experience in ICD 10 coding.
At least there (3) years of clinical coding and/or auditing experience in a hospital environment..
Computer PC literacy required.
Must be an excellent communicator, negotiator and have great organizational skills.
Strong knowledge of clinical documentation guidelines required.
Must be able to work collaboratively and independently.
Must be flexible with responsibilities in order to meet departmental needs.
Must be able to demonstrate initiative and the ability to work in a fast-paced environment with proficiency in multi-tasking and prioritization.
Experience in computerized hospital/health information management systems and software applications are required.

Preferred Skills but Not Required:

Certification in Clinical Documentation Integrity (CCDS, CDIP) strongly desired.
Certified in coding (CCS) preferred.
Meditech Expanse experience preferred.
Technical knowledge of ICD-10, DRG and APR assignment and prospective payment methodologies preferred.
Must be detail oriented, have the ability to work independently, exercise good judgment and be resourceful.
Must display proficient communication skills, both written and verbal.
Must be able to speak clearly and concisely while presenting.
Ability to write reports independent of management review is a plus.
Experience and/or knowledge of regulatory compliance issues facing the healthcare industry is also a plus.
Requires strong interpersonal skills to work with key stakeholders, physicians and/or clients and staff to implement positive/effective change.
Demonstrated customer-oriented management style.
Ability to manage execution by balancing time, resources, and quality constraints to achieve goals required.
Focused on team and collaboration.
Ability to address critical issues and demonstrate self-initiation. Ability to think critically and analytically, anticipate challenges and trends.
Computer knowledge of MS Office, including Word, Excel, and PowerPoint is preferred.
Working knowledge of automated system designs is preferred.

Note: Savista is required by state specific laws to include the salary range for this role when hiring a resident in applicable locations. The salary range for this role is from $82,000.00 to 92,000.00. However, specific compensation for the role will vary within the above range based on many factors including but not limited to geographic location, candidate experience, applicable certifications, and skills.

SAVISTA is an Equal Opportunity Employer and does not discriminate against any employee or applicant for employment because of race, color, age, veteran status, disability, national origin, sex, sexual orientation, religion, gender identity or any other federal, state or local protected class.

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