Clinical Documentation Integrity Specialist
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Monday-Friday 7:30 AM - 4:00 PM
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GENERAL SUMMARY
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The Clinical Documentation Integrity Specialist is responsible for reviewing inpatient medical records to assess and procure accurate and complete documentation of the patients’ diagnosis and procedures. Reports to department leadership.
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ESSENTIAL DUTIES AND RESPONSIBILITIES
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Reviews Inpatient Clinical Documentation, ensuring that physicians’ and clinicians’ documentation, accurately reflect the patient’s conditions, diagnoses, treatments, and interventions, resulting in accurate reimbursement.
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Reviews to ensure the clinical documentation, reflects the patient’s severity of illness, quality of care and resources used.
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Provides education to the physicians and ancillary providers regarding accurate, specific and compliant clinical documentation.
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Acts as a resource for other departments regarding the importance of clinical documentation integrity, and the need to clinically document following the Federal and State regulations.
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Performs all other duties as assigned.
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LICENSES AND/OR CERTIFICATIONS
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Required Licenses and/or Certifications
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- Current Virginia state license as a Registered Nurse or Registered Nurse holding a valid Compact State license required.
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Preferred Licenses and/or Certifications
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- Certified Documentation Improvement Professional (CDIP) or Certified Clinical Documentation Specialist (CCDS) certification or must be credentialed through AHIMA or ACDIS, within two years of start preferred.
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MINIMUM EDUCATION AND EXPERIENCE REQUIREMENTS
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Required Education and Experience
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- Registered Nurse -Professional knowledge of nursing theory and practice at a level normally acquired through the completion of an accredited School of Nursing.
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Preferred Education and Experience
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- Pediatric and or Clinical Documentation or Utilization Management preferred.
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Required Knowledge, Skills and Abilities
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- Experience with applying clinical criteria to a medical record review with a Clinical Documentation Integrity focus.
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- Knowledge of healthcare payment systems, specifically the MS-DRG, Tricare and APR-DRG reimbursement systems.
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- Ability to form positive and collaborative relationships, with Physicians, HIM colleagues, the Physician Advisor and other hospital staff.
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- Competent using Microsoft Office Suite, and different Electronic Medical Records.
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- Requires Strong organizational, clinical critical thinking and analytical skills.
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Preferred Knowledge, Skills and Abilities
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- Technical and professional knowledge and skills for clinical operations of the service area, usually acquired through 3 - 5 years’ progressive Clinical/Supervisory experience in a practice setting.
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WORKING CONDITIONS
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PHYSICAL REQUIREMENTS
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