Clinical Documentation Improvement Specialist

Job Description

Responsibilities

• Implements clinical documentation improvement (CDI) activities in an effort to support accuracy and quality of the patient records and to ensure that coded diagnoses are an accurate reflection of the patient's clinical status and care.

• Reviews the medical record documentation and clinical indicators and works with providers to ensure a complete and accurate medical record.

• An accurate medical record is important for the patient, for continuity of care by the next provider, and to demonstrate high quality care by the physician and the hospital.

• Identify potential gaps in clinical documentation for inpatient and payer populations as directed throughout the hospitalization.

• Educate physicians and key healthcare providers regarding clinical documentation improvement and the need for accurate and complete documentation in the health record.

Requirements

• Associate degree in Nursing required, Bachelor's degree preferred.

• Current RN license through the state of Alabama required.

• In addition, the following are highly desired: RHIT, RHIA, CDIP, CCDS, CCS and ICD-10 certification or designation.

• Must possess at least five years of acute hospital nursing experience (e.g. medical/surgical unit, intensive care).

• Experience in Utilization Management/Case Management, Critical Care, patient outcomes/quality management and/or inpatient coding considered a plus. ICU/Critical Care Experience strongly desired.

• Prior experience in clinical documentation improvement, ICD coding and MS-DRGs preferred.

• Prior experience educating physicians/providers preferred.

• Previous experience working in a clinical documentation improvement department or as a consultant strongly encouraged.

• Minimum of one-year auditing experience strongly encouraged.

• This individual must possess a comprehensive knowledge of medical terminology, disease processes and clinical competency.

• Candidate must possess excellent communication (verbal and written), interpersonal, collaboration and relationship-building skills.

• Strong critical thinking skills and ability to integrate knowledge is necessary.

• Prioritization and organizational skills required.

• Must exhibit the ability to educate members of the healthcare team about clinical documentation. Individual must demonstrate data quality and integrity skills.

• To perform this job successfully, an individual should have strong working knowledge of word processing software, spreadsheet software and reporting software.

• Also, experience working with encoder software, clinical documentation improvement software and the electronic medical record is preferred.

• English is required for both verbal and written communication, ability to communicate effectively at a high level is required.

Grandview Medical Center, a 434-bed regional referral center and tertiary-care facility, is located in Birmingham, AL., and is accredited by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). Grandview Medical Center offers programs and services in all medical and surgical areas, including Cardiology, Oncology, Neurology, Women's Health, Mental Health, Digestive Diseases, Orthopedics, Physical Medicine and Rehab, Sports Medicine and Emergency Care. There are more than 600 physicians on the Grandview medical staff representing 30 specialties and subspecialties. The hospital has been named an accredited program for Metabolic and Bariatric surgery by ASMBS & ACS as well as an accredited chest pain center. Grandview Medical Center provides equal employment opportunity to all employees and applicants for employment regardless of any individual's race, color, religion, sex, sexual orientation, gender identity, national origin, age, citizenship, military status, disability, genetic information or any other protected class status in accordance with applicable federal, state, and local laws.