Unit:

MEDICAL RECORDS

Job Summary:

The RN Clinical Documentation Improvement Specialist performs concurrent review of the medical record, issues concurrent physician inquiries, and interacts with the medical staff and other caregivers in an effort to assure complete and accurate documentation of the patient's clinical picture and the treatment provided. The CDS acts as a liaison between Coding professionals and the medical staff.

The ideal candidate has the following qualities:
Superior clinical assessment skills.
Knowledge of care delivery documentation systems and related medical record documents.
 Working knowledge of reimbursement systems and regulatory coding systems (e.g. ICD-9CM, HCPCS, MS-DRGS).
Building and Maintaining Strategic Working Relationships - develops collaborative relationships to facilitate the accomplishment of work goals. 
Possesses excellent interpersonal skills in building, negotiating and maintaining crucial relationships.
Obtains and promotes appropriate clinical documentation through extensive interaction with physicians, nursing staff, other patient caregivers, and coding staff to ensure that the documentation of the level of service rendered to the patient and the patient's clinical complexity is complete and accurate.
Reviews medical records and identifies potential gaps in clinical documentation for specified patient types (e.g., I/P, O/P, etc.)  and payer populations (e.g., Medicare, Medicaid, Blue Cross/Blue Shield, etc.) as directed on admission and throughout hospitalization.
Queries physicians and other caregivers as necessary via approved written communication mechanisms to obtain accurate and complete documentation that supports the severity of patient illness, intensity of services and risk of mortality.
Completes concurrent review on 85% of assigned population.
Achieves and maintains 95% accuracy rate.
Works closely with coding staff to assure documentation of discharge diagnoses and any co-existing co morbidities or complications to completely reflect the patient's clinical status and care.
Demonstrates basic knowledge of coding standards and application to ongoing evaluation of medical record documentation.
Develops and implements plans for both formal and informal education of physician, nursing, and other clinical staff.

Identifies strategies through data gathering and analysis of trends to establish recommendations for sustained work process changes that facilitate complete, accurate clinical documentation.
Consistently meets established productivity targets for record review.
Other duties as assigned

Requirements:

5+ to 7 years of experience 
Registered Nurse required
Minimum Education - Bachelor's Degree

Critical Care Experience 
 RHIA, RHIT, CCS or other related certification