Clinical Documentation Specialist III

Job Profile Summary

The role of the Clinical Documentation Integrity (CDI) Specialist III is responsible for concurrent and retrospect review and analysis of the medical record to improve overall quality and completeness of clinical documentation. The CDS III facilitates and obtains appropriate modifications to clinical documentation, including clinical conditions and procedures, for accurate representation of severity of illness, expected risk of mortality, and complexity of care of the patient through extensive interaction with physicians, HIM professionals, and other interdisciplinary team members. Contributes to CDI and documentation initiatives related to provider engagement, relationship establishment and maintenance, provider education, including formal and informal education plans, as well as participates in department and organization projects related to documentation improvement. The CDS III is a Subject Matter Expert also responsible for initiating special CDI projects for process improvement and participates in hospital meetings such as UR, Case Management, Quality, and meetings with Physician Advisors/Champions.

Job Description

Minimum Qualifications:

1. Bachelor’s Degree in Nursing

2. Active Registered Nurse (RN) license in Massachusetts or compact state

3. Five years’ experience in an acute-care hospital setting (ICU, ED, Critical Care, strong Med/Surg Specialty) or equivalent case management, utilization review, denials management, or progressive leadership in an acute-care hospital setting

4. Four years’ experience in Clinical Documentation Improvement/Integrity

5. Advanced clinical expertise and extensive knowledge of complex disease processes with broad clinical experience is required.

6. CCDS and/or CDIP Certification

Preferred Qualifications:

1. Master’s Degree in Nursing, Healthcare Management, Healthcare Administration, Business Administration, or other related field

2. CCS Certification

Duties & Responsibilities:

The duties and responsibilities listed below are intended to describe the general nature of work and are not intended to be an all-inclusive list. Other duties and responsibilities may be assigned.

1. Demonstrates knowledge of Official Guidelines for Coding and Reporting, APR-DRG and MS-DRG Classification System to ensure industry best practice standards and regulatory compliance related to the CDI and coding functions.

2. Performs initial concurrent review of new patients every day and concurrent re-reviews approximately every two days until the patient is discharged except weekends and company-approved holidays.

3. Performs retrospective review of discharged encounters, accurately identifies discrepancies in documentation, and facilitates timeliness of appropriate documentation or coding modifications.

4. Demonstrates a strong understanding of case mix index, MCC/CC capture, severity of illness/risk of mortality, LOS, risk adjustment diagnoses.

5. Provide education to physicians and other members of the patient care team to ensure their understanding of the clarification process and the desired outcome of documentation excellence for severity of illness and intensity of care. Provides feedback and education in proficient verbal and written formats both remotely and onsite.

6. Serves as a resource and mentor to CDS I and CDS II team members.

7. Assist in quality audits of CDS I and CDS II team members. Identify the need for additional training and resources needed for the success of the CDI Team.

8. Demonstrates ability to analyze CDI data and prepare presentations for education and insight into CDI trends and outcomes.

9. Works closely with the Quality team to identify and ensure that the provider documentation is complete to address PSIs, HACs, Mortality, and Vizient variables, as well as other Quality indicators where indicated.

10. Collaborates with case management and utilization review team to ensure that documentation is clearly substantiated in the record to prevent denials as appropriate as well as to provide clear documentation for level of care.

11. Responsible for effective time management and efficient prioritization to achieve and maintain key operating metrics consistent with CDI Department needs and requirements.

12. Demonstrates proficiency in current and emerging technologies.

13. Independently takes proactive steps toward problem solving, conflict resolution, and troubleshooting of technology errors.

14. Responsible for self-development and completes all mandatory and assigned education by established deadlines.

15. Attends scheduled meetings and continuing education programs.

16. Actively encourages collaboration and possesses excellent interpersonal skills in building and maintaining crucial relationships.

Physical Requirements:

1. Professional office environment with typical office requirements such as computers, phones, photocopiers, filing cabinets, etc.

2. This is largely a sedentary role, which involves sitting most of the time, but may involve movements such as walking, standing, reaching, ascending / descending stairs, and operate office equipment.

3. Frequently required to speak, hear, communicate, and exchange information.

4. Able to see and read computer displays, read fine print, and/or normal type size print and distinguish letters, numbers and symbols.

5. Occasionally lift and/or move up to 25 pounds.

Skills & Abilities:

1. Ability to read and write in the English language. Ability to understand and speak English fluently enough to be easily understood by patients, hospital personnel, physicians, and visitors.

2. Strong critical thinking skills and sound clinical background with a working knowledge of disease processes, anatomy and physiology, and treatment regimens.

3. Ability to analyze and interpret clinical information in the patient’s medical record.

4. Strong written and verbal communication skills demonstrated by the ability to effectively communicate with physicians and other clinicians.

5. Knowledge of ICD-10, AHIMA and Coding Guidelines, healthcare regulations, reimbursement, and documentation requirements.

6. Willingness to work collaboratively within a team.

7. Open, flexible, and adaptable to a changing environment as the CDI industry continues to change and evolve.

8. High level Computer literacy and efficiency with technology, Microsoft Office Suite (including Word, Excel, Teams), Zoom, Epic, 3M360.

9. Ability to use good judgment in an emergency situation.

10. Commitment to upholding and providing services in a manner that is congruent with the Hospital’s mission statement.