Clinical Doc Improvement Specialist / Full Time / Sharp Grossmont Hospital / RN Licensure
Company: SHARP HEALTHCARE
Location: La Mesa
Posted on: May 11, 2022
Job Description:
This is a full time position located at Sharp Grossmont
Hospital. Current California RN License is required. -What You Will
DoThe Clinical Documentation Improvement Specialist (CDIS) reviews
inpatient medical records while patients are still in-house
(concurrent review) for proper documentation resulting in
appropriate reimbursement, severity of illness, risk of mortality,
quality measures and risk adjustment. This review includes new
admissions to the facility, as well as re-reviews every two to
three days until the patients are discharged. The CDIS communicates
with clinicians and physicians to ensure timely and accurate
documentation for all designated payer(s) and provides training and
education as needed. The role collaborates with many departments
such as HIM, Quality, and Service lines to improve documentation,
reimbursement and Quality measures internally for Sharp Healthcare
as well as publicly reported measures.Required Qualifications
- 5 Years Experience in nursing or other clinical area of an
acute care facility
- California Registered Nurse (RN) - CA Board of Registered
Nursing -REQUIREDPreferred Qualifications
- Bachelor's Degree in Nursing
- Emergency or critical care nursing background
- Experience working with an EHR, preferably Cerner
MillenniumOther Qualification Requirements
- CDIS certification preferred.Essential Functions
- Coding complianceInteracts with Clinical Coding Specialists and
Second Level Reviewers to establish a strong, collaborative
relationship with the coding team.Facilitates physician queries and
assists in obtaining clinically complete and specific documentation
needed for compliant coding.Assures any clarification is documented
appropriately in the patient's record according to
policy.Follows-up with physician, if appropriate.
- Communication and teamworkDemonstrates positive interpersonal
relations in dealing with all members of the team (i.e. co-workers,
supervisors, physicians, etc.) as evidenced by: communicating in a
positive and productive manner; demonstrating respect for team
members; maintaining a positive attitude; about assignments and
team members; and working collaboratively; and cooperating with
other departments/units.
- DocumentationImproves accuracy documentation specificity and
completeness with real-time interactive communication and education
of physicians, clinicians, and other involved parties regarding the
necessity of providing complete and clear documentation of the care
provided throughout a patient's stay.Includes day to day processes
of working daily with physicians to improve documentation capture
of diagnosis specificity, all secondary diagnoses, and procedures
during the patient stay.Achieved using clinical knowledge to deploy
queries, face-to-face communications, and/or other educational
programs and tools useful and necessary to achieve this goal.
- Leadership in area of expertiseCollaborates with Clinical
Informaticists, Physician Informaticists, and Specialists regarding
EMR documentation, education and system improvements.Demonstrates
content expertise regarding applications and business operations by
supporting clients and receiving customer feedback.Manages client
expectations, priorities, and attainment of project goals through
effective communication.Recommends workflow and technical
improvements to various electronic documentation tools.
- Professional developmentAbides by all documentation and coding
conventions, ethical and professional standards and rules
established by the Center for Medicare and Medicaid (CMS), and the
American Health Information Management Association (AHIMA) for
assignment of diagnostic and procedure codes and ultimately a
working DRG.Adheres to AHIMA query guidelines.Remains current with
coding and documentation improvement techniques to support accuracy
of codes and the resulting working DRG assigned.Participates in
educational programs and in-services in order to maintain and
exceed excellence in documentation and coding skills.Information
will include the AHA Coding Clinic publication, pharmacology,
laboratory, disease processes, and new/emerging
technologies.Participates in the peer review process as both a
reviewer and reviewee as a means of education and feedback to peers
and self.
- QualityCollaborates with the Quality Team to determine if
documentation supports or negates an AHRQ patient Safety indicator
and or Hospital Acquired ConditionReviews record to identify
appropriate risk adjustment diagnoses which are relevant and may
impact the scoring or quality of the documentationKnowledge,
Skills, and Abilities
- Strong clinical skills including understanding of clinical
disease process, pathophysiology and treatment plans.
- Effective interpersonal skills in order to interact effectively
with physicians and all levels of hospital personnel.
- Organization and prioritization skills.
- Effective written and verbal communications skills.
- Analytical skills.
- Working knowledge of regulatory coding guidelines
preferred.
- Proficient with MS Office applications.Sharp HealthCare is an
equal opportunity/affirmative action employer. All qualified
applicants will receive consideration for employment without regard
to race, religion, color, national origin, gender, gender identity,
sexual orientation, age, status as a protected veteran, among other
things, or status as a qualified individual with disability or any
other protected classBachelor's Degree in Nursing; California
Registered Nurse (RN) - CA Board of Registered Nursing
Keywords: SHARP HEALTHCARE, La Mesa , Clinical Doc Improvement Specialist / Full Time / Sharp Grossmont Hospital / RN Licensure, Healthcare , La Mesa, California
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