Clinical Document Integrity Specialist – PRN – Cheyenne Regional Medical Center – Cheyenne, WY

ROLE SUMMARY

The Clinical Document Integrity Specialist (CDIS) is the key medical staff representative to and for the hospital’s clinical and coding documentation improvement initiative. The CDIS is responsible for improving the overall quality and completeness of physician and nurse practitioner and physician assistant documentation of diagnoses and procedures using terminology integral to HIPAA related transaction sets, primarily in inpatient and observation admissions. The DIS facilitates clinical documentation improvement through extensive daily interaction with physicians, caregivers, case management and coding staff to achieve timely, accurate, and complete documentation. Educates all members of the patient care team on clinical documentation improvement.

CORE RESPONSIBILITIES

• Concurrently review inpatient and observation medical records to identify documentation opportunities:
  • Reviews all clinical documentation to assure all pertinent conditions are documented to reflect severity of illness and acuity of care.
  • Establishes the working DRG assignment. When necessary, collaborates with coding liaison to determine accurate working DRG.
  • Identifies and queries physicians, nurse practitioners, and physicians’ assistants of potential clarifications related to the principal diagnoses, comorbid conditions and complications, and/or procedures based upon industry standards, hospital policy, and clinical indicators; assures physician documents their responses within the record in a compliant manner.
  • Ensures timely data entry and closure of cases in electronic database;
  • Conducts follow-up reviews to ensure points of clarification have been recorded in the patient’s medical record.
  • Responsible for the identification of core measures related to the quality initiatives in the organization.
• Communicates with physicians regarding documentation issues to ensure immediate resolution:
  • Confers with physician on completeness, timeliness and appropriateness of clinical documentation.
  • Attends physician rounds for patients on assigned services. Reviews and discusses documentation on patient records with physician during or immediately following rounds.
  • Provides physicians with guidelines on complete and timely documentation;
  • Implements appropriate and timely referrals to physician advisors;
  • Participates in resolving physician documentation issues and keeps management informed of unresolved issues.
• Educates physicians and caregivers on the importance of complete and accurate clinical documentation as it relates to patient acuity, severity of illness, physician profiling/scorecards/core measures, and regulatory reimbursement guidelines:
  • Advises and assists in development of documentation education programs;
  • Participates in meetings with physicians to discuss patient care documentation trends and improvement opportunities.
  • Identifies educational opportunities with other caregivers and support personnel.
• Assesses improvement in the quality of clinical documentation for area of responsibility:
  • Monitors results of interactions and follows up with queries until resolution.
  • Collects data showing activities performed and improvement made.
  • Identifies process improvement opportunities related to clinical documentation.
  • Prepares administrative and clinical statistical reports as requested.
• Provides for a complete medical record at patient discharge which accurately captures the patient’s acuity and severity levels.
  • Ensures documentation that results in accurate clinical data to measure and report outcomes which support appropriate reimbursement for the level of services rendered to the patient.
  • Retrospective reviews of records for identification of missing/clarification information
  • Other duties as assigned.

The above statements are intended to describe the general nature and level of work performed by people assigned to this job. They are not intended to be an exhaustive list of all responsibilities, duties and skills required of personnel so classified and employees may be required to perform other duties as assigned.

SKILLS, KNOWLEDGE, AND ABILITIES

• Must possess a high level of clinical knowledge regarding the patient population served in order to participate collaboratively with all members of the care team
• Must demonstrate knowledge of the principles of disease definitions and natural history, possess the ability to assess data reflective of the patient’s clinical status, interpret the appropriate information needed to identify each patient’s acuity and severity of illness.
• Works with minimal supervision
• Must be able to communicate verbally and written to individuals of varying educational levels; this includes being respectful of physicians by using tact and diplomacy.
• Demonstrates ability to use technology and appropriate software to support their daily activities.
• Ability to provide occasional evening, weekend, and holiday coverage.
• Knowledge and competency in: positive interpersonal and communication skills; critical analysis skills; ability to resolve complaints/problems; customer focused philosophy of service delivery; ability and willingness to work as an integral member of a multi-disciplinary team, computer literacy.