Clinical Documentation Specialist

We are currently seeking a Clinical Documentation Specialist to join our team. This full-time role will primarily work remotely (days).

• Conducts initial and continued-stay concurrent reviews on inpatient admissions and documents findings using the designated CDI software, Coding software and Epic electronic record as necessary/ requires proficiency in abstracting the needed clinical information and data used for clinical documentation
• Identifies procedures and secondary diagnoses for co-morbidities/complications and documents appropriately within the designated CDI software, Coding software and Epic electronic record as needed to accurately calculate the correct DRG assignment
• Identifies documentation issues within the medical record around ICD-10-CM Diagnosis and ICD-10 PCS procedure codes
• Communicates via a query process to the Medical Staff, Advanced practice practitioners (APP's) and other providers, including medical residents as necessary, via written/verbal communication to obtain accurate and complete provider documentation
• Assigns baseline and working DRG (APR or MS DRG), along with Severity of illness and Risk of Mortality to reviews using ICD-10-CM /PSC codes and procedures to all reviews
• Ensures the timeliness of all written and verbal queries from providers to ensure proper documentation is obtained and placed in the medical record before patient discharge whenever possible
• Identifies potential Patient safety indictors (PSI) and Hospital acquired conditions (HAC) codes and notifies appropriate staff personnel for further review
• Conducts post discharge reviews and reconciliation of DRG assignment and baseline DRG, ensuring correct outcome for all coding queries responses
• Educates physicians, clinicians, and other involved parties regarding the necessity of providing complete and clear documentation of the care provided. This may require the use of computer software and developing education using software such as PowerPoint
• Applies federal and state documentation and coding (ICD-10-CM/PCS) guidelines to ensure physician and hospital compliance. Maintains current knowledge of coding/documentation information including the AHA's Coding Clinic publication, pharmacology, laboratory, disease processes, and new/emerging technologies to ensure accuracy of code assignment and compliance
• Identifies documentation trends and issues and reports these to CDI leadership, as well as the inpatient coding management and staff as needed
• Interacts with coding team to resolve documentation and coding issues and ensure proper DRG assignment
• Be able to prepare and provide service-specific information and education to physicians and other care providers, related to provider documentation and its effects on coding, compliance, profiling and reimbursement
• Participates in educational programs and in-services in order to maintain clinical documentation requirements, knowledge and ICD- 10-CM /PCS coding requirements
• Portrays a professional manner in dress and all communication skills
• Must have effective interpersonal skills to effectively interact, communicate, and maintain good working relationships with Medical Staff, Advanced Practice Practitioners (APP's), other provers and team members
• Must be able to work with minimal supervision and assist others in completing the work of the team
• Performs other tasks as assigned

• Graduation from an accredited school of nursing, and two (2) years of professional nursing experience preferably in a medical or surgical area of an acute hospital setting

• Graduation from an AHIMA accredited program as a Registered Health Information Administrator (RHIA) and at least three (3) years of recent inpatient coding experience

• Graduation from an AHIMA accredited program as a Registered Health Information Technician (RHIT) and at least four (4) years of recent inpatient coding experience

• An approved equivalent combination of education and experience

• Experience in CDI activities

License/Certifications:

• Maintain current licensure by the Minnesota Board of Nursing as a Registered Nurse(RN)

-OR-

• Registration as a Registered Health Information Administrator (RHIA) or Registered Health Information Technician (RHIT) by the American Health Information Management Association.