Clinical Documentation (CDI) Specialist
Dallas Regional Medical Center - Mesquite, TX

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1. Concurrent Review
1.1 Conducts concurrent review based on specified criteria, often focusing on specific area(s) of opportunity to improve medical record documentation practices. This review includes new admissions to the facility as well as re-reviews every two to three days until the patients are discharged.
1.2 Identifies opportunities to justify the intensity of service and severity of illness in the patients treated and shares this information in a interdisciplinary approach with physicians, clinical staff, case managers and coding staff with the goal of obtaining documentation excellence supporting the care provided to the patient.
1.3 The CDS with the Case Manager will proactively monitor DRG assignment to ensure documentation supports the DRG based on the diagnosis, care, and treatment being provided to the patient. Provides clinical team with a concurrent population of patients who are potentially in core measure quality review.
1.4 Recommends post-discharge query as appropriate when documentation supporting severity of illness and/or intensity of service was not realized prior to patient discharge from care.
1.5 Develops action plans to improve documentation in the open record as identified through the concurrent review process.
1.6 Enters concurrent ICD-9 codes in Meta Health to identify concurrent core measure patients. Has a concurrent report available for Core Measure abstractors to review concurrent patients.
2. Query Process
2.1 CDS is responsible for developing appropriate physician query tools and processes in accordance with Medicare and AHIMA.
2.2 Provides documentation and supportive training in the use of query tools and processes to Case Managers and Coding Staff.
2.3 Provides education to physicians and other clinical providers to ensure their understanding of the query process and the desired outcome of documenting our excellence for severity of illness and intensity of care.
3. Reporting/ Educating
3.1 Produces reports as requested and produces a monthly summary report of cases reviewed.
3.2 Keeps daily production of number of cases reviewed and the number of cases queried for weekly evaluation of output.
3.3 Educates specific physicians, attends physician department meetings (Cardiology, Surgery, etc.) and presents reports on the progress of the concurrent reviews.
4. Other Duties
4.1 Serves as an internal consultant for Administration, Ancillary Departments, Physicians, Case Management, Clinicians and others with regard to appropriate diagnosis and procedural coding in accordance with federal, state, and private; rules and regulations.
4.2 Serves as an integral member on teams supporting quality of care and documentation excellence for our patients.
4.3 Researches and monitors professional journals and websites (specifically including Medicare) for new developments to ensure organizational adaptation and compliance.
4.4 Follows guidelines for coding and documentation to ensure physician and hospital compliance. Remains current with coding information to assure accuracy of codes assigned based on documentation. Information will include the Coding Clinic publication, pharmacology, laboratory, disease processes, and new/emerging technologies. Participates in education programs and inservices in order to maintain and exceed excellence in coding skills. Maintains a library of information beneficial to the work.
4.5 Maintains established hospital and departmental policies and procedures, objectives, performance improvement program, safety, environmental and infection control standards. Maintain confidentiality and security levels to protect medical/legal patient care documentation.
5. Adheres to and follows the principles of the hospitals Customer Relations Program.
5.1 Promotes quality guest relations by identifying both internal and external customers; acknowledging customers promptly; and, using expressions that convey respect, understanding, and enhance self-esteem.
5.2 Creates a positive impression through effective use of telephone skills such as answering the phone by the third ring, identification of self and department, listening attentively, personalizing the conversation and verifying information.
5.3 Creates a supportive climate for customers by allowing customers to express themselves, addressing their concerns as being real and encouraging two-way communication.

Education: High school diploma required, Associates Degree or higher preferred; Nurse Graduate, or Graduate or Certificate from an AHIMA accredited college; AHIMA credentials preferred: RHIA, RHIT, or CCS.

Experience: This position requires a Nurse with coding experience or an AHIMA Certified Coder with Clinical Documentation experience in an acute care setting; requires extensive knowledge ICD-9-CM and CPT principles and guidelines; extensive knowledge of reimbursement systems, Medicare, Federal, State and Local payer rules and regulations; strong leadership and interpersonal skills in oral and written communications; knowledge of coding and abstracting systems and encoders; and proficiency in use of Microsoft Office Word and Excel.