Clinical Documentation Improvement Specialist - White Plains Hospital

Position Summary: The CDIS facilitates accurate documentation for severity of illness and quality in the medical record. This involves extensive record review, interaction with physicians, health information management professionals, and nursing staff. Active participation in team meetings and education of staff in the Clinical Documentation Improvement Program (CDIP) process is a key role. Essential Functions and Responsibilities Includes the Following: 1. Understands and adheres to the WPH Performance Standards, Policies and Behaviors. 2. Reviews medical record for completeness and accuracy for severity of illness (SOI) and quality using the Compliant Documentation Management Program documentation strategies 3. Performs accurate and timely record review 4. Recognize opportunities for documentation improvement 5. Initiates severity illness worksheet for inpatients 6. Formulate clinically credible documentation clarifications (queries) 7. Request documentation clarifications as appropriate for SOI, Core Measures, and Patient Safety 8. Effective and appropriate communication with physicians 9. Timely follow up on all cases and resolution of those with clinical documentation clarifications 10. Participate in Task Force Meetings (Coder/CDI) 11. Communicates with coders and resolves discrepancies 12. Performs accurate input data into the Track 13. Performs all other related duties as assigned. Education & Experience RequirementsEducation: Graduation from a program of nursing, BSN, preferred. Current state Registered Nurse license Score (minimum of 70%) on the Clinical Competency Assessment (CCA) Experience: 5 years of adult acute care experience in med/surg, critical care, emergency room, or PACU. Core Competencies

• Organizational, analytical, writing and interpersonal skills
• Dependable, self-directed and pleasant
• Critical thinking, problem solving and deductive reasoning skills
• Knowledge of Pathophysiology and Disease Process
• Basic Computer skills – familiarity with Windows based software programs
• Knowledge of disease processes in all clinical specialties, anatomy & physiology and pharmacology and must have the ability
• to correlate abnormal lab results to disease processes
• Knowledge of official coding guidelines and documentation requirements related to the Inpatient Prospective Payment System
• Knowledge of regulatory environment
• Understand and communicate differences between Medicare Part A and Part B guidelines and how they impact DRG
• assignments
• Knowledge of Core Measure and Patient Safety Indicators

Physical/Mental Demands/Requirements & Work Environment May be exposed to chemicals necessary to perform required tasks. Any hazardous chemicals the employee may be exposed to are listed in the hospital's SDS (Safety Data Sheet) data base and may be accessed through the hospital's Intranet site (Employee Tools/SDS Access). A copy of the SDS data base can also be found at the hospital switchboard, saved on a disc. Must be able to alternate between remaining stationary at the work station and walking to patient units. Constantly utilizes/operates computer to access information. Must be able to utilize multiple screens to view and document. Flexible and able to adapt to changes. Primary Population Served Check appropriate box(s) below: Neonatal (birth – 28 days) Patients with exceptional communication needs Infant (29 days – less than 1 year) Patients with developmental delays Pediatric (1 – 12 years) Adolescent (13 – 17 years) Adult (18 – 64 years) Patients with cultural needs Patients under isolation precautions Patients at end of life Geriatric (> 65 years) Bariatric Patients with weight related comorbidities Non-patient care population All populations The responsibilities and tasks outlined in this job description are not exhaustive and may change as determined by the needsof White Plains Hospital.

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