CLINICAL DOCUMENTATION IMPROVEMENT SPECIALIST
White Plains Hospital Center - White Plains, NY

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Associate's Degree

Position Summary:
Facilitates and obtains appropriate documentation of clinical conditions and/or procedures to support the severity of illness and complexity of care of the patient; Provides education regarding documentation guidelines

Job Responsibilities:
Completes initial reviews of patient records within 24-48 hours of admission for specified patient population to: (a) evaluate documentation needed to assign the principal diagnosis, pertinent secondary diagnoses and procedures for accurate DRG assignment and severity of illness; and (b) initiates a review worksheet

Conducts follow-up reviews of patients every 2-3 days to support and assign a working or final DRG assignment upon patient discharge, as necessary

Queries physicians regarding missing, unclear, or conflicting health record documentation by requesting and obtaining additional documentation within the health record when needed

Educates physicians and key healthcare providers regarding clinical documentation improvement and the need for accurate and complete documentation in the health record

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

Maintains statistical database(s) to track results of the CDI Program, identifies opportunities for improvement and validate program effectiveness; identifies trends and provides regular reports to Management and Medical Staff
Educates the Medical Staff regarding specific documentation needs and reporting and reimbursement issues identified through daily and retrospective documentation reviews and aggregate data analysis
Facilitates changes in processes required to capture needed documentation, such as EMR template design
Partners with the coding professionals to ensure accuracy of diagnostic and procedural data and completeness of supporting documentation to determine a working and final DRG and severity of illness
Reviews and clarifies clinical issues in the health record with the coding professionals that would support an accurate DRG assignment and severity of illness

Education, Training, Licensure and Experience Requirements:
Education: Bachelor’s Degree in Nursing preferred or Health Information Management
Professional (RHIA, RHIT or CCS) ( CCDS and/or CCS credentials
preferred)

Experience: An RN must have a minimum of 3-5 years Med/Surg, Critical Care or Case
Management experience. A Health Information Management Professional
must have a minimum of of 5 years of inpatient coding experience in an
acute care setting Must be PC literate and facile in navigating the EMR

Current Employees

White Plains Hospital Center - 23 months ago - save job - copy to clipboard - block
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About this company
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White Plains Hospital is a voluntary, not-for-profit health care organization with the primary mission of offering high quality, acute...