Clinical Documentation Specialist 1

As a Clinical Documentation Specialist 1, you will conduct reviews of electronic medical records on a defined inpatient population while patients are being treated on nursing units. To help achieve our mission, you will interact with providers via the query process, phone, paging systems, email or secure texting applications. Interacting with CDS Remote, CDS 2, CDI Educator/Auditor, CQCs and Coding Professionals to ensure complete and compliant provider documentation to support MS-DRG, APR-DRG, severity of Illness (SOI), Risk of Mortality (ROM) is of vital importance. Your ability to follow up with providers (physicians, APPs) regarding pending queries related to compliant documentation for DRG revenue assurance, compliance, quality outcomes and ICD10 is required.

Job Responsibilities

• Conducts initial and follow up concurrent reviews of medical records for assigned patients in the time frame and frequency defined for productive work.
• Maintains query rate, response rate and agreement rate in line with established performance benchmarks.
• Assists with reviewing records at different Inova hospitals as needed and under supervision of CDS II, CDI Manager, CDI Director.
• Participates in all coding education on ICD-10, MS-DRG and quality outcome measures as well as compliance requirements related to query (AHIMA Practice brief).
• Maintains competency in use of CDI applications to process daily work lists and results of record reviews and queries.
• Enters all required data into CDI applications to enable Coders and Coding Auditors to determine disposition of concurrent queries in order to assign the final MS-DRG as well as APR-DRG, SOI and ROM.
• Interacts with Coding Auditors on any questions related to CDI coding, MS-DRG and APR-DRG involved in the preparation of concurrent queries and final coding.
• Assists with any post-discharge (retrospective) queries as requested by CDI leadership.
• Provides at the elbow and electronic support to providers regarding best practice documentation standards and the query process. Provides 1:1 provider education within daily workflow and participates in group education sessions as requested by CDI Leadership.
• Participates in special projects and audits as directed by CDI Leadership.
• Onsite requirement up to 20-30% of full time hours (2-3 days per pay period).
  

Additional Requirements

Education:

Bachelor's degree or higher in Nursing or Medicine (e.g. BSN, MD, MBBS, NP, PA).

Alternatively, a combination of Registered Nurse (RN) or Registered Health Information Technician (RHIT) with certification in coding or clinical documentation improvement and 1 year of work experience with Inpatient CDI, Coding or DRG Assurance: RN/RHIT/RHIA with CCS/CCDS/CDIP and 1 year of experience.

Experience:

3 years of health care related work experience to include
at least 3 months of recent (within 12 months) Inpatient CDI, DRG assurance or Coding experience.

Training:

Receives at least 90 percent accuracy rate on DRG assurance test, ICD-10 CDI test or equivalent., CDI, DRG Assurance, or Inpatient Coding training.

Certifications:

CCS or CCDS or CDIP required for RN/RHIT candidates.

Skills:
Possesses strong clinical skills and knowledge.
Proficient with use of various computer applications.
Ability to quickly learn new systems.
Excellent verbal and written communication skills.
Strong interpersonal skills particularly in working with physicians, nurses and coding auditors.
Ability to work as part of a team.

As a Clinical Documentation Specialist 1, you will conduct reviews of electronic medical records on a defined inpatient population while patients are being treated on nursing units. To help achieve our mission, you will interact with providers via the query process, phone, paging systems, email or secure texting applications. Interacting with CDS Remote, CDS 2, CDI Educator/Auditor, CQCs and Coding Professionals to ensure complete and compliant provider documentation to support MS-DRG, APR-DRG, severity of Illness (SOI), Risk of Mortality (ROM) is of vital importance. Your ability to follow up with providers (physicians, APPs) regarding pending queries related to compliant documentation for DRG revenue assurance, compliance, quality outcomes and ICD10 is required.

Job Responsibilities

• Conducts initial and follow up concurrent reviews of medical records for assigned patients in the time frame and frequency defined for productive work.
• Maintains query rate, response rate and agreement rate in line with established performance benchmarks.
• Assists with reviewing records at different Inova hospitals as needed and under supervision of CDS II, CDI Manager, CDI Director.
• Participates in all coding education on ICD-10, MS-DRG and quality outcome measures as well as compliance requirements related to query (AHIMA Practice brief).
• Maintains competency in use of CDI applications to process daily work lists and results of record reviews and queries.
• Enters all required data into CDI applications to enable Coders and Coding Auditors to determine disposition of concurrent queries in order to assign the final MS-DRG as well as APR-DRG, SOI and ROM.
• Interacts with Coding Auditors on any questions related to CDI coding, MS-DRG and APR-DRG involved in the preparation of concurrent queries and final coding.
• Assists with any post-discharge (retrospective) queries as requested by CDI leadership.
• Provides at the elbow and electronic support to providers regarding best practice documentation standards and the query process. Provides 1:1 provider education within daily workflow and participates in group education sessions as requested by CDI Leadership.
• Participates in special projects and audits as directed by CDI Leadership.
• Onsite requirement up to 20-30% of full time hours (2-3 days per pay period).
  

Additional Requirements

Education:

Bachelor's degree or higher in Nursing or Medicine (e.g. BSN, MD, MBBS, NP, PA).

Alternatively, a combination of Registered Nurse (RN) or Registered Health Information Technician (RHIT) with certification in coding or clinical documentation improvement and 1 year of work experience with Inpatient CDI, Coding or DRG Assurance: RN/RHIT/RHIA with CCS/CCDS/CDIP and 1 year of experience.

Experience:

3 years of health care related work experience to include
at least 3 months of recent (within 12 months) Inpatient CDI, DRG assurance or Coding experience.

Training:

Receives at least 90 percent accuracy rate on DRG assurance test, ICD-10 CDI test or equivalent., CDI, DRG Assurance, or Inpatient Coding training.

Certifications:

CCS or CCDS or CDIP required for RN/RHIT candidates.

Skills:
Possesses strong clinical skills and knowledge.
Proficient with use of various computer applications.
Ability to quickly learn new systems.
Excellent verbal and written communication skills.
Strong interpersonal skills particularly in working with physicians, nurses and coding auditors.
Ability to work as part of a team.