Job Description
About the position Responsibilities • Provides expert level review of inpatient clinical records within 24-48 hours of admit; identifies gaps in clinical documentation that need clarification for accurate code assignment. • Conducts daily follow-up communication with providers regarding existing clarifications to obtain needed documentation specificity. • Provides expert level leadership for overall improvement in clinical documentation by providing proficient level review and assessment, and effectively articulating recommendations for improvement. • Actively communicates with providers at all levels to clarify information and communicate documentation requirements for appropriate diagnoses based on severity of illness and risk of mortality. • Provides timely feedback to providers regarding clinical documentation opportunities for improvement and successes. • Ensures effective utilization of CDI software to document all verbal, written, electronic clarification activity. • Proactively develops a reciprocal relationship with the HIM Coding Professionals. • Engages and consults with Physician Advisor /VPMA when needed, per the escalation process, to resolve provider issues regarding answering clarifications. Requirements • CCDS or CDIP certification, or ability to obtain within 6 months of employment. • 7+ years of acute care hospital clinical RN experience OR Foreign Medical Graduate with 2+ years of experience working as a Clinical Documentation Improvement Specialist in an acute hospital setting. • 1+ years of CDI experience. • Experience communicating & working closely with Physicians. • Proficiency using a PC in a Windows environment, including Microsoft Word, Excel, Power Point and Electronic Medical Records. • Ability to work daytime PST hours. Nice-to-haves • BSN degree or equivalent. • Optum 360 e-CAC experience. • Epic experience. Benefits • Comprehensive benefits package • Incentive and recognition programs • Equity stock purchase • 401k contribution Apply tot his job