Job Description
Love what you do; Love where you live The Clinical Documentation Improvement Specialist facilitates improvement in the quality and completeness of patient records on a concurrent basis, using a multi-disciplinary process. The CDIS applies clinical knowledge and coding knowledge to evaluate clinical indicators, diagnoses, and treatment plan for assigned inpatients, to identify gaps in physician documentation.
Required Behaviors: •As you go about fulfilling this mission, your work habits and work relationships should embody SJRMC's values. These values are our culture, our identity as an organization:
Sacred Trust, Personal Reverence, Thoughtful Anticipation, Team Accountability and Creative Vitality ask more of us than merely completing some list of tasks. Our values ask for a deeper level of commitment, and what is asked of us we freely give because we believe in our mission.
Required Qualifications: - Registered Nurse
- Minimum of 3 years strong clinical background in acute care
- Current NM Licensure
- Excellent written and verbal communication skills
- Analytical thinking skills
- Team-oriented
- Basic computer skills
- Highly-organized
Preferred Qualifications: - BSN Certified
- Clinical Documentation Specialist (CCDS)
- Coding experience
Duties and Responsibilities :
- Comprehensively reviews patient records, concurrently and retrospectively, to assure a complete and accurate representation of the severity of illness and use of resources.
- Assigns Working DRG
- Works closely with physicians, Case Management staff, and Coding to review documentation coding practices analyzing whether documentation supports the acuity of the patients.
- Identifies gaps in physician documentation and facilitates appropriate documentation improvement interventions with physicians.
- Identifies Clinical Documentation Improvement (CDI) best practices, benchmarks and improvement strategies to augment compliance objectives.
- Stays current on information pertaining to coding, compliance, clinical guidelines and payer requirements as it relates to MSDRG assignment, documentation and other payment requirements.
- Each employee is responsible for implementing SJRMC's Service Standards into their daily work:
Safety, Courtesy, Effectiveness, and Stewardship - Perform related duties as required.
Physical Demands and Environmental Work Conditions :
•Prolonged standing/sitting/walking
•Fast paced environment
•High level of activity with many interruptions
•Possible exposure to communicable disease
•Repetitive motions (i.e.; keyboard usage)
Sensory Requirements: The employee will need to be able to hear:
•Alarms on equipment/fire alarms/overhead announcements
•Patients/family/physician verbal discussion
•Feedback from other healthcare providers
The employee will need to be able to see:
•Focus on close-up and distant objects
•Have intact: peripheral vision and depth perception
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