Clinical Documentation Improvement Specialist

Overview

Riverside University Health System-Medical Center has opportunities for Inpatient Clinical Documentation Improvement Specialists. These positions have either a Monday-Friday or a Tuesday-Saturday, 9/80, hybrid in-person/remote schedule. Occasional travel will be required, as incumbents will rotate through the main hospital campus to provide CDI support and resources to clinical staff. During initial training and departmental onboarding, incumbents will work on-site full-time.

Ideal candidates will have a strong understanding of PSI and HAC metrics and the ability to ensure accurate documentation and coding that appropriately reflects patient acuity and quality outcomes in an acute care environment.

Clinical Documentation Improvement (CDI) Specialists review medical record documentation to assure completeness, clarity, accuracy, and overall quality in accordance with Coding and Clinical Documentation Improvement goals. This classification is responsible for concurrent clinical documentation review, with an emphasis on completeness and accuracy of healthcare provider documentation related to types of medical services provided and the level of patient illness severity throughout hospital admission/discharge.

The CDI Specialist is experienced in clinical documentation review and capable of implementing methods of improving the accuracy, specificity, and completeness of patient-care documentation. The major role of a CDI Specialist is to serve as an institutional subject matter expert and as a resource for interpretation and application of coding rules and regulations; and, when necessary, write physician queries to obtain additional documentation or clarification.

The incumbent provides guidance to physicians, clinicians, and coders regarding documentation requirements. A CDI Specialist is expected to possess an in-depth understanding of the substantive contents of a medical record, including extensive knowledge of a wide variety of specialized medical terminology, as well as medical diagnosis, treatment plans, and protocols.

Riverside University Health System-Medical Center consistently receives national recognition for its progressive and innovative care, as well as being known as one of the top employers in the region. The 439-bed Medical Center is a designated Stroke Center, Level II Trauma Center, and is the only Pediatric ICU in the region. For more information on RUHS-Medical Center, please visit ruhealth.org.

• Complete admission reviews of patients  records within 24-hours of admission to evaluate and analyze documentation in order to assign the principal diagnosis, pertinent secondary diagnoses and procedures for accurate and optimal CMS-Diagnostic Related Group (CMS-DRG) assignment.
• Initiate and perform concurrent documentation reviews of selected inpatient and outpatient records to clarify conditions/diagnoses and procedures where inadequate or conflicting documentation exists and conduct follow-up reviews as necessary.
• Develop and implement methods of improving the clarity, accuracy and completeness of clinical documentation; monitor and evaluate coding outcomes and provide periodic status to medical center departments and committees.
• Communicate with and serve as a resource for physicians, nurses and other healthcare providers to facilitate complete and accurate documentation of the patient record; query physicians regarding missing, unclear or conflicting medical record documentation and obtain additional documentation; keep physician leaders informed of pertinent data, documentation trends and opportunities for learning and improvement related to documentation integrity.
• Code a wide variety of procedures and primary and secondary diagnoses according to the applicable International Classification of Diseases (ICD-10-CM or subsequent adaptation) coding system and CPT-4 procedural coding system; prepare pertinent data from medical charts according to criteria established by OSHPD and the Medical Audit Committee or individual physicians for various studies, statistical indexing and preparation of summary reports to various regulatory agencies.
• Collect data for performance improvement and report findings and outcomes; participate in the analysis and trending of statistical data for specified patient populations to identify opportunities for improvement.
• Participate in revenue cycle meetings, providing data relative to reimbursement concerns; educate physicians and healthcare providers regarding documentation matters related to coding, billing and reimbursements.

OPTION I

Education: Graduation from an accredited college or university with a bachelor s degree in nursing.

Experience: Three years as a registered nurse in an acute care hospital. One year of inpatient CDI experience strongly preferred.

License/Certificate: Must possess and maintain a current valid license to practice as a Registered Nurse in the State of…