This position assists the CDI team, providers, and other key stakeholders in meeting revenue, quality, and productivity goals and objectives by identifying opportunities for continuous quality improvement and knowledge advancement. Involved with testing and education on system upgrades and new system implementations. Conducts regular quality audits within the CDI Specialists group to ensure consistency and compliance with state and national standards. This role emphasizes denial management, educational program development, and provider education.
MINIMUM QUALIFICATIONS:
EDUCATION, CERTIFICATION, AND/OR LICENSURE:
1. Must have one of the following Education and Certification Qualifications:
Graduate of Health Information Technology (HIT) or equivalent program with RHIT (Registered Health Information Technician) or RHIA (Registered Health Information Administrator) OR;
Current Registered Nurse license issued by the state in which services will be provided or current multi-state Registered Nurse license through the enhanced Nurse Licensure Compact (eNLC). OR;
Current Licensed Practical Nurse license issued by the state in which services will be provided or current multi-state Licensed Practical Nurse license through the enhanced Nurse Licensure Compact (eNLC).
2. Must have the CDIP (Certified Documentation Improvement Practitioner) through American Health Information Management Associate (AHIMA) OR CCDS (Certified Clinical Documentation Specialist) through the Association of Clinical Documentation Integrity Specialists (ACDIS) within One (1) year of hire.
EXPERIENCE:
1. Experience required according to license type:
If Licensed Registered RN (RN)Seven (7) years of experience in inpatient acute care setting.
If Licensed Practical Nurse (LPN), eight (8) years of clinical experience in acute care setting.
If Graduate of Health Information Technology (HIT) or equivalent program with RHIT or RHIA, Seven (7) years’ experience in inpatient acute care hospital coding.
PREFERRED QUALIFICATIONS:
EDUCATION, CERTIFICATION, AND/OR LICENSURE:
1. Bachelor’s Degree in Health Information Management, or Nursing, or other related healthcare field.
2. Certified Clinical Documentation Specialist Outpatient (CCDS-O).
EXPERIENCE:
1. Previous supervisory or project management experience preferred.
CORE DUTIES AND RESPONSIBILITIES: The statements described here are intended to describe the general nature of work being performed by people assigned to this position. They are not intended to be constructed as an all-inclusive list of all responsibilities and duties. Other duties may be assigned.
1. Responsible for planning, development, and implementation of clinical documentation education program for providers, APPs, and clinical staff. Assists individual and group education sessions on documentation improvement initiatives to department chairs, providers, APPs, and other clinical staff. Assists with new provider onboarding sessions to provide education and training resources related to Inpatient and Outpatient CDI.
2. Provides ongoing education to the CDI Specialists team on documentation guidelines, regulations, and chart review functions in order to meet and maintain organizational goals and objectives, regulatory compliance, policies and procedures, and personnel management.
3. Serves as mentor and key educator for CDI Specialists team and develops CDI apprenticeship/orientation program to include auditing, mentoring and education modules.
4. Responsible analyzing data to ascertain where stronger education for providers and staff.
5. Serves as expert CDI resource to clinical documentation improvement specialists, coders,, revenue cycle, and other specialty groups and meetings.
6. Promotes compliance with CMS, Medicare documentation, third party payers, LCDs, NCDs and coding and billing regulations.
7. Participates in the processes to assess and improve the services provided and compliance with regulatory requirements. Reports results assessment and improvement processes to the appropriate administrative levels.
8. Conducts facilitation of quarterly quality assurance audits to ensure CDI workflow meets quality performance, improvement standards. Works closely with CDI Manager on education opportunities in areas of need.
7. Acts as Super user for all CDI-related EHR Systems necessary for complete an accurate documentation and EMR Data Governance. Updates policies and procedures for those areas of responsibility. In-services appropriate staff regarding changes in these areas.
8. Continually communicates with CDI Staff, CDI leadership, Coding leadership team, Medical Staff, Medical Director, Physician Advisors, Department Chairman, Department Administrators, and Population Health.
9. Works closely with CDI specialists to identify areas of non-specific documentation and improve documentation templates in support of clinical protocols.
PHYSICAL REQUIREMENTS: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
1. Must be able to sit for long periods of time.
2. Must have visual and hearing acuity within the normal range.
3. Must have manual dexterity needed to operate computer and office equipment.
WORKING ENVIRONMENT: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
1. Standard office environment.
2. May be exposed to standard patient care environment.
3. Visual strain may be encountered in viewing computer screens, spreadsheets, and other written material.
4. May require travel.
SKILLS AND ABILITIES:
1. Must possess excellent written and verbal communication skills, as well as interpersonal skills necessary to communicate effectively.
2. Must possess the knowledge of related provider healthcare compliance, revenue cycle operations, and auditing techniques required.
3. Must possess the ability to mentor, educate and train others.
4. Must meet quality and productivity standards.
5. Must be able to handle high stress and critical situations in a calm and professional manner.
6. Must be able to concentrate and maintain accuracy during constant interruptions.
7. Must possess independent decision-making ability.
8. Must possess the ability to prioritize job duties.
9. Must be able to adapt to changes in the workplace and work assignments.
10. Must possess organizational and time management skills.
11. Must possess the knowledge of anatomy, physiology and medical terminology.
12. Must possess analytical and problem solving skills.
13. Must be proficient in office software programs.
14. Must possess the ability to analyze complex data and reports.
Additional Job Description:
Scheduled Weekly Hours:
40
Shift:
Exempt/Non-Exempt:
United States of America (Exempt)
Company:
SYSTEM West Virginia University Health System
Cost Center:
538 SYSTEM HIM CDI
