Clinical Documentation Specialist II Full Time Days

DMC Harper University Hospital has distinguished itself in surgery and medicine and is known for its clinical expertise and innovative research. A specialty referral hospital, Harper has established Centers of Excellence in neurosciences, bariatric surgery, vascular services, multidisciplinary cardiovascular services, hypertension, stroke prevention and heart failure.

POSITION SUMMARY

The Clinical Documentation Specialist (CDI) level II reports to the Market Clinical Documentation Specialist Manager. Under limited direction works collaboratively with medical, nursing and ancillary staff, and case managers and coders to improve the overall accuracy, quality and completeness of clinical documentation in accordance with clinical documentation guidelines and established policies/procedures. The CDI II will be responsible for performing initial and follow up reviews of selected patient accounts both while hospitalized or after discharge to identify appropriate documentation accuracy and identify gaps and opportunities to reflect the level of service rendered to all patients. Ensures the accuracy and completeness of clinical information used for measuring and reporting quality services and performance of specific quality outcomes. Oversees clinical documentation patterns and trends to identify areas of improvement in documentation and performance measures. Educates all members of the patient care team regarding clinical documentation needs, changes to clinical documentation guidelines, coding and reimbursement issues, and quality performance documentation requirements on an on-going basis. Develops and conducts on-going Performance Documentation education for new staff including case managers, coders, physicians, residents, nurses, and allied health professionals. Compiles, analyzes, and evaluates quality and clinical data collected as part of an integrated system-wide program of clinical improvement and documentation requirements. Provide full CDI coverage to the designated facility as per the CDI Department guidelines and directions. CDI level II is an intermediate level position for experienced CDI and must demonstrates all skills of CDS I & II with <5% error rate.

KNOWLEDGE, SKILLS, ABILITIES
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The list below is representative of the knowledge, skill and/or ability. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Required:
* Analytical ability and comprehensive knowledge base to gather and interpret clinical documentation data, to identify discrepancies, problems or issues, and to determine methods for ensuring compliance with clinical documentation policies and procedures. Ability to analyze data for patterns and trends.
* Strong critical thinking skills and ability to integrate knowledge. Excellent observation, communication, and decision-making abilities. Strong presentation skills in order to articulate the program to physician and other health care professionals in order to educate and teach clinical documentation requirements and educate all members of the care team.
* Ability to prioritize work, focus on completion of tasks and meet deadlines through strong organizational skills. cope with stressful situations, manage multiple and sometimes conflicting priorities simultaneously. Demonstrates motivation and can work as a focused, self-directed individual.
* High-level communication skills both verbal and written. Ability to collaborate and use assertive interpersonal skills to discuss clinical documentation issues and work effectively with all levels of internal personnel such as coders, physicians, nursing and allied health professionals.
* Demonstrated team player skills and encouraged a spirit of cooperation among CDI team, clinicians, coders, physicians, etc., and direct others toward objectives that contribute to the success of the program.
* Knowledge of clinical documentation guidelines, policies and procedures, and the requirements of compliant query and communication with clinicians.
* Strong computer skills and knowledge of Email, Microsoft Word, Microsoft Excel or other software packages including database and spreadsheet programs. Preferred:
* Demonstrated leadership skills.
* Have experience working with Iodine, 3M encoder, Artifact or Cerner-PowerChart
* Skilled in conflict resolution

Qualifications:

EDUCATION / EXPERIENCE
Include minimum education, technical training, and/or experience for the job.

Required:
* Graduate from an accredited School of Nursing with RN or LPN, BSN.
* Or Graduate from an accredited School of Medicine with MD or MBBS (either foreign or domestic),
* And must have a minimum of 1 - year experience working as an Inpatient CDI in an acute care hospital.
Preferred:
* Graduate from an accredited Health Informatics program for clinical documentation integrity.
* 3 -years' experience or more working as an inpatient CDI in an acute care hospital.
* 5 - years' experience or more in a clinical setting with acute patient care.

REQUIRED CERTIFICATIONS/LICENSURE
Include minimum certification required to perform the job.

Required:
* RN, or LPN with an active license
* Or MD, DO or MBBS
Preferred:
* BSN, NP, MBA, MPH, MHA or MSN
* CDI related certificate (RHIA, RHIT, CCS, CDIP, CCDS)
* USMLE Certificate

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