PURPOSE: The Clinical Documentation Improvement Specialist (CDIS) serves as a liaison for Case Management, working closely with the medical staff, nursing staff and Coding Staff in support of excellence in patient information documented in the medical record. The primary purpose of this role is to ensure that all diagnoses, care, and treatment are documented in support of patient care and accurate DRG assignment. Improves coding specificity by educating physicians, clinicians, and other interested parties regarding the necessity of providing complete and clear documentation of the care provided. This includes medical necessity, capturing complications/comorbidities during the patient’s stay. The CDIS is accountable for concurrent review of medical records to track documentation supporting the severity of the illness and the resources utilized. A concentrated effort is put forth on patients concurrently with diagnosis which have the potential to be in the population of core measure assignment for quality of care review. The CDIS assists in the development of educational resources necessary to assure compliance with federal, state, and private rules and regulations on data collection, coding, and reimbursement. The CDIS also provides a mechanism and guidelines to assure documentation of pertinent clinical findings in the medical record and clarifies ambiguous documentation by the physician.
ESSENTIAL JOB FUNCTIONS: Concurrent Review, Query Process, Reporting/Educating.
QUALIFICATIONS: RN, BSN, RHIA, RHIT, or CCS or combination there of. A minimum of five years experience in nursing or other clinical area, coding, process improvement, or utilization review/case management in an acute care facility. Coding skills with experience in ICD-9CM, working knowledge of the AHA Coding Clinic, and DRG assignment. Strong interpersonal skills in order to interact effectively with all levels of hospital personnel. Effective written and verbal communication skills. Proficiency in use of Microsoft Office Word, Excel, and Powerpoint.
Must abide by Charlotte Regional's guiding principles of SUPER CARE:
S ense of Ownership
E levator Etiquette
A ttitude is friendly and warm
Charlotte Regional Medical Center - Adding Life to your Years
With a family-like atmosphere, current technology, competitive wages and benefits, this award-winning hospital is looking for talented and dedicated individuals like you! Our Communities and Region Punta Gorda The name Punta Gorda means "Broad Point" and dates back to the landing of Ponce de Leon in 1513. It is the only incorporated city in Charlotte County and is more than 14 miles square with slightly more than 14,000 residents. Situated approximately 100 miles south of Tampa on the Gulf Coast with easy access from I-75, this community continues to offer leisurely, uncongested and unhurried living. Charlotte Harbor flanks the northwest side of the city offering 129 square miles of sparkling water, clear sunshine, fishing at its finest, wildlife in abundance and a casual, friendly atmosphere that appeals to those who are seeking the natural pleasures of life. The recently revitalized downtown has cobblestone streets and gas lamp streetlights. The residential area features many brick streets lined with stately royal palms and many old Florida-era tin-roofed homes boasting wide verandas.
About Charlotte Regional Medical Center Located in Punta Gorda, Charlotte Regional Medical Center is a full-service hospital dedicated to abiding by the mission of: Caring professionals dedicated to serving our community. Founded in 1947, 208-bed Charlotte Regional is Joint Commission Accredited and an award-winning hospital, with stroke services, orthopedics, and respiratory programs earning national distinction. For more information, visit www.CharlotteRegional.com.
Excellent Benefits • Medical, Dental, Vision• 401k• Life Insurance, AD&D• Short and Long Term Disability• Child Care Reimbursement (up to $50 per week)• On-Site Child Care / Sick Child Care • Tuition Assistance• Flexible Scheduling• Generous Shift Differentials•Free Gym Membership • Discounted Theme Park Tickets
Charlotte Regional Medical Center - 10 months ago