HCA, Hospital Corporation of America Clinical Documentation Improvement Specialist in Bedford, Texas

JOB SUMMARY (Primary purpose of the position.)

GENERAL SUMMARY OF DUTIES – The Clinical Documentation Improvement (CDI) Specialist conducts concurrent review of the clinical documentation in the medical record to achieve more accurate and detailed documentation. Facilitates and obtains appropriate physician documentation for any clinical conditions or procedures to support the appropriate severity of illness, expected risk of mortality, and complexity of care of the patient which will in turn improve the quality of patient care, more accurately portray the facility’s quality outcomes ratings, reduce compliance risks, and capture appropriate reimbursement.

GENERAL RESPONSIBILITIES (The essential responsibilities and accountabilities of this position including interactions with other departments and outside vendors, if applicable.)

  • Practices and adheres to the “Code of Conduct” philosophy and “Mission and Value Statement”

  • Obtains and promotes appropriate clinical documentation through extensive interaction with physicians, nursing staff, and other patient caregivers to ensure that the documentation of the level of service rendered to the patient and the patient’s clinical complexity is complete and accurate.

  • Reviews medical records and identifies potential gaps in clinical documentation

  • Performs a thorough chart review to identify that the Principal diagnosis, present on admission (POA) indicators and co-morbidities/complications are documented appropriately

  • Assigns concurrent MS-DRGs for identified populations by conducting initial and re-reviews Queries physicians using approved query forms for missing, unclear, or conflicting documentation by requesting and obtaining additional documentation within the health record to obtain accurate and complete documentation that supports the severity of patient illness and risk of mortality

  • Interacts with physicians to resolve queries prior to patient discharge

  • Collaborates with case managers, nursing staff, and other ancillary staff to help resolve physician queries prior to patient discharge

  • Educates physicians and key healthcare providers regarding clinical documentation improvement and the need for accurate and complete documentation in the health record; provides formal and informal in-services as needed to physicians and ancillary staff

  • Participates in the analysis and trending of statistical data to identify opportunities for improvement

  • Identifies strategies for work process changes that facilitate complete, accurate clinical/physician documentation

  • Documents reviews and other pertinent information concurrently by the established deadlines

  • Documents reviews and other pertinent information post discharge by the established deadlines

  • Works closely with designated Health Information Service Center (HSC) coding staff to assure documentation of discharge diagnoses and any co-existing co-morbidities are a complete reflection of the patient’s clinical status and care

  • Reviews HSC coding feedback as a means of continuous education and self-evaluation

  • Reviews HSC coding post discharge query trending as a means of concurrent physician interaction opportunities

  • Assists with preparation and presentation of clinical documentation monitoring/trending reports for review with physicians and hospital leadership

  • Demonstrates ongoing knowledge of clinical requirements and coding standards for evaluation of medical record documentation

  • Completes all assigned education by the established deadlines

  • Provides coverage for other CDI staff

  • Assists with training CDI staff

  • Maintains the ability to be flexible and prioritize daily responsibilities

  • Other duties as assigned

    Experience (Minimumamount of specifically related experience which is required to perform the role at this level. Note in Other additional specific exp.)
    ☐ Less than 1 year ☐ 1-3 years ☒ 3-5 years ☐ 3-7 years

    ☐ More than 7 years ☒ Other preferred/required experience :
    Required: Minimum 3 – 5years recent clinical experience. Preferred: Critical care experience. EDUCATION (Minimumformal academic training which typically provides the knowledge and skills necessary for successful job performance. Note in Other if experience may be substituted.)
    ☐ High School Graduate/Equivalent ☒ College Graduate Preferred ☐ College Graduate Required Undergrad ☐ College Graduate Required Graduate ☐ College Graduate Required Other

    ☐ Technical Training ☒ Other as Noted: • CDI Coder: Bachelor’s or Associate’s degree in Health Information Management preferred • CDI Coder: Minimum 3-5 years recent acute care inpatient coding • CDI Nurse: Minimum 3-5 years recent clinical experience in an acute care environment • CDI Nurse: Critical care experience preferred • CDI Nurse: BSN preferred CERTIFICATION/LICESURE • CDI Nurse: RN required; Texas State RN license or compact license is accepted • CDI Coder: RHIA, RHIT, CCS preferred • CCDS or CDIP preferred SPECIAL QUALIFICATIONS (Required licenses, certificates, specific skills, personal traits, e.g., RN, CPA, able to type 90 wpm, detail orientation.)

  • Building and Maintaining Strategic Working Relationships – develops collaborative relationships to facilitate the accomplishment of work goals; possesses excellent interpersonal skills in building, negotiating and maintaining crucial relationships

  • Building Trust – interacts with others in a way that gives them confidence in one’s intentions and those of the organization

  • Organization - proactively prioritizes initiatives, effectively manages resources and keen ability to multi-task

  • Communication - communicates clearly, proactively and concisely; listens actively; alters communication style as appropriate; writing and speaking skills indicate good grammar style and tone

  • Teamwork – balances team and individual responsibilities; objective and open to other’s views; gives and welcomes feedback; contributes to positive team spirit; puts success of team above own interest

  • Adaptability – maintaining effectiveness when experiencing major changes in work tasks or the work environment; able to adapt to change in environment and/or circumstances with a positive outlook; and adjusting effectively to work within new work structures, processes, requirements, or cultures

  • Initiative – independently takes prompt proactive steps towards problem resolution

  • Customer Service – adheres to the Customer Service expectations and philosophy established at physical work location; shows respect for the customer; anticipates/responds quickly to customer needs/concerns; keeps commitments

  • Proficient clinical assessment skills, including understanding of disease processes and pathophysiology

  • Thorough understanding of inpatient coding guidelines and physician documentation impact

  • Working knowledge of the inpatient prospective payment system (IPPS)

  • Policies & Procedures - articulate knowledge and understanding of organizational policies, procedures and systems

  • PC skills - demonstrate proficiency in software applications as required

Title: Clinical Documentation Improvement Specialist

Location: Texas-Bedford-DFW Support Services

Requisition ID: 09375-85132