Clinical Document Integrity Specialist

Job Requirements A Day in the Life of a Clinical Document Integrity Specialist

The Clinical Document Integrity Specialist (CDIS) is a key representative to and for the organization's clinical and coding documentation improvement initiatives. The CDIS is responsible for improving the overall quality and completeness of provider documentation of diagnoses and procedures using terminology integral to HIPAA related transaction sets. The CDIS facilitates clinical documentation improvement through extensive daily interaction with physicians, caregivers, case management and coding staff to achieve timely, accurate, and complete documentation.Educates all members of the patient care team on clinical documentation improvement.

• Why Work at Cheyenne Regional?
• Employer Sponsored Medical, Dental, and Vision Plans 403(b) and 457(b) retirement options with 4% employer match Life Insurance Short Term and Long-Term Disability Insurance Employer Sponsored Wellness Program Employee Assistance Program ANCC Magnet Hospital 21 PTO days per year (increases with tenure) Tuition Reimbursement Program Dedicated Loan Forgiveness Advisory Service Here is What You Will Be Doing: Reviews medical records upon admission, concurrently, and at discharge to identify documentation opportunities and ensures all pertinent conditions are documented timely to reflect severity of illness and acuity of care.
• Develops training materials and educates physicians and caregivers on the importance of complete and accurate clinical documentation as it relates to patient acuity, severity of illness, physician profiling/scorecards/core measures, and regulatory reimbursement guidelines.
• Participates in meetings and attends rounds with physicians/providers for patients on assigned services.
• Reviews and discusses documentation on patient records with physician/provider during or immediately following rounds.
• Communicates and seeks clarifications from providers for questions related to principal diagnoses, comorbid conditions, complications, and/or procedures based on industry standards, hospital policy, or clinical indicators.
• Conducts reviews to ensure clarifications have been recorded in the patient’s medical record timely and accurately.
• Informs management of unresolved issues.
• Establishes the working DRG assignment collaborating with coding liaison as necessary.
• Ensures timely data entry and closure of cases in electronic database Responsible for the identification of core measures related to the quality initiatives in the organization.
• Collects data to assess improvements in quality of clinical documentation and success of initiatives.
• Identifies additional opportunities for process improvement by preparing administrative and clinical statistical reports along with promoting and participating in LEAN practices and strategies.
• Performs retrospective reviews of records for identification of missing/clarification information Desired Skills: Strong knowledge of clinical practices and patient population to collaborate with all members of the care team Strong knowledge of disease definitions and natural history Ability to assess/interpret data reflecting patient clinical status Ability to work with limited supervision Professional verbal, written, and interpersonal communication skills Ability to use technology and software supporting daily activities Ability to provide occasional evening, weekend, and holiday coverage.

Our team makes a difference every day by providing trusted healthcare expertise through a passionate and I.N.S.P.I.R.E.(ing) approach with a personal touch. By living our values, we aim to achieve our goal of becoming a 5-star rated hospital, providing critical support and resources to our community and the greater region we serve. If you are eager to make a difference and passionate about healthcare, we encourage you to apply today!