Job Summary:
The Clinical Documentation Specialist is an experienced Clinical Documentation Nurse who has obtained knowledge and expertise in all patient populations across the enterprise to provide comprehensive Clinical Documentation Integrity (CDI) chart reviews. Facilitates modifications to clinical documentation to ensure appropriate reimbursement is received for the level of service rendered. Ensures the accuracy and completeness of clinical information used for measuring and reporting clinical and quality outcomes.
Job Responsibilities:
-Collects and assesses data within CDI software systems.
-Independently applies experience and critical thinking skills to identify opportunities for documentation improvement that support the program and organizational goals.
-Facilitates modifications to clinical documentation to ensure appropriate reimbursement is received for the level of service rendered. Improves quality and completeness of clinical documentation by performing initial, follow-up, reconciliation reviews while adhering to organizational workflows and ACDIS / AHIMA guidelines.
-Provides training and guidance to Associate CDS nurses.
-Identifies and reviews complex clinical issues / service line trends upon reconciliation process via level process with coding. Facilitates and enhances procedural coding practices. Collaborates with physicians, midlevel providers, nursing staff, other patient providers, and coding staff to ensure appropriate reimbursement is received for the level of service rendered and to capture Quality specific codes related to patient encounter specific DRG's.
-Ensure points of clarification have been recorded in the patient's chart.
-Maintains records that support appropriate financial reimbursement (DRG and CMI) and organization quality benefit rankings. Other duties as assigned.
Required Skills & Experience:
-Minimum of five (5) years of acute care nursing experience is required.
-Minimum of one (1) year of CDI experience in a hospital setting is required.
-Efficient use of MS Office products (Excel, Outlook, Word), WebEx and Epic (or similar EMR).
-Excellent communication, negotiation, troubleshooting, and presentation skills.
-Ability to read and correlate an extensive variety of medical / surgical medical treatments and monitoring to clinical conditions.
-Ability to interact with all levels of organization.
-Ability to document and maintain process documentation.
-Excellent follow-through from initiation to conclusion.
-Working knowledge related to MSDRG and APRDRG payer trends and rules.
-Working knowledge related DRG and CMI impacts.
-Working knowledge of coding guidelines and coding clinics.
Required Education:
-Bachelor's degree in nursing.
Required Certifications & Licensure:
-Requires current state of Wisconsin Registered Nurse License or a Multi-state Nursing License from a participating state in the NLC (Nurse Licensure Compact).
Preferred Certifications & Licensure:
-Advanced certification related to CDI (CCDS, CDIP) is preferred.
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