Full Job Description
Position Summary:
The Quality Improvement Clinical Documentation Specialist (QICDS) is a professional role responsible for leading the quality and safety documentation initiatives to ensure optimal medical record optimization in quality of care and clinical documentation standards. This role requires expertise in medical record review, performance improvement and regulatory standards for health information management (HIM), coding and CMS rules and regulations, and quality of care standards. The QICDS is also responsible for concurrent and retrospective review of potential quality and safety conditions including Patient Safety Indicators (PSIs), Hospital Acquired Conditions (HACs), and mortality review processes including software tools. The QICDS is responsible for active participation in team meetings, dissemination of clinical documentation, PSI/HAC and mortality education for staff and providers on an ongoing basis.
QICDS may m entor, train or lead other CDS or QICDS during their orientation period and assist them with Clinical Documentation Integrity (CDI) policies, procedures, standard work, and systems on an ongoing basis.
Position Responsibilities:
Key Areas of Responsibility
Documentation Review
• Provides extensive and accurate reviews of medical records within specified timelines.
• Recognizes opportunities for documentation improvement on records with potential PSIs and/or HACs, and then formulates clinically credible and compliant clarifications/queries.
• Reviews mortality records and uses software tools to identify clinically credible and compliant queries to reflect accurate Principal Diagnosis (PDX), comorbid conditions, severity of illness, risk of mortality, and mortality risk predictors. Works with Coding and Quality teams, documents in Optum and EPIC the appropriate information about codes/conditions to include in top 25 -30 codes as well as risk scoring and other documentation as needed by clinical teams.
• May perform any clinical documentation review as needed
• Follows up on all cases especially those with clinical documentation clarifications/queries. Provides education to providers on responding to queries in the medical record and other CDI and Quality topics.
• Utilizes internal and external data to identify issues and trends that impact patient safety and quality of care. Escalates to organizational leaders and assists in creating and presenting education to address any identified opportunities.
• Performs quality and safety monitoring activities necessary to support clinical and administrative staff with ongoing evaluation of care processes and outcomes.
• Meets program quality and productivity guidelines and standards.
• Participates in Coding/CDI meetings and CDI H3W work group.
• Inputs review workflows and accurate data and CDI query impact into Optum and EPIC.
• May enter appropriate data into Redcap or other systems for provider review of quality related outcomes.
• Collaborates with inpatient coders to determine appropriate Diagnosis Related Groups (MS-DRG, APR-DRGs, etc.) and ICD-10 code assignment for compliance, reimbursement, and quality outcomes.
• Meets revenue cycle goals, Key Performance Indicators (KPIs), quality and productivity standards).
Training & Special Projects
• Creates training materials and presentations to inform the organization of successes and opportunities. Trains and mentors new colleagues. Acts as a Subject Matter Expert to the organization on regulatory documentation including CMS, as well as understanding internal policies, procedures, standard work, and workflows.
Communication
• Seeks clarification from physicians, nursing, and other staff in cases where documentation is absent, ambiguous, or contradictory.
• Collaborates with HIM coding staff to resolve discrepancies.
• Collaborates with Regional Quality Management Teams
Other
• Abides by The Ethical Standards for Clinical Documentation Improvement (CDI) Professionals as set forth by the American Health Information Management Association.
• Participates in other assignments and special projects as assigned.
Working Relationships:
Job Title of Individual(s) Reports To: HHC Clinical Documentation Manager or Supervisor (proposed - TBD)
Qualifications:
Requirements and Specifications:
Education:
• Minimum: Bachelor's degree in related field OR an Associate's Degree in Nursing or progression towards Bachelor's Degree
• Preferred: Master's Degree in Nursing or associated discipline
Experience
• Minimum:
• Registered nurse (RN) with minimum of 5 years recent clinical experience in acute care hospital, Intensive Care Unit (ICU), Cardiac Care Unit (CCU), strong Med/Surg. or equivalent
OR
• 2+ years Quality Management experience in PSI/HAC and mortality risk systems.
• Preferred:
• Registered Nurse (RN) with 8+ year's clinical experience in acute care hospital, Intensive Care Unit (ICU), Cardiac Care Unit (CCU), strong Med/Surg. or equivalent
OR
• 4+ years Quality Management experience in PSI/HAC and mortality risk systems.
Licensure, Certification, Registration
• Minimum: RN licensed to practice in CT
• Preferred:
• Certified Clinical Documentation Specialist (CCDS) certification
OR
• Certified Clinical Documentation Professional (CDIP) certification
• CPHQ, or other quality certification
Language Skills
• Strong written and verbal communication skills
Knowledge, Skills and Ability Requirements:
• Ability to learn/develop the skills necessary to perform Clinical Documentation review of medical records.
• Knowledge of Pathophysiology and Disease Process.
• Working knowledge of clinical information.
• Ability to understand and communicate the impact of CC/MCC's and other variables on the assignment of the various DRG methodologies.
• Must be able to function independently.
• Knowledge of AHRQ Patient safety indicator (PSI) specifications and CMS Hospital-Acquired Conditions (HAC).
• Solid analytical capabilities.
• Strong organizational skills.
• Strong critical thinking, problem solving and deductive reasoning skills.
• Ability to handle multiple priorities and increasing responsibility
• Strong ability to listen to and acknowledge ideas and expressions of others attentively.
• Strong ability to converse clearly using appropriate verbal and written communications as well as conveying positive body language.
• Ability to collaborate with others to achieve a common goal through mutual cooperation.
• Ability to influence others for positive and productive outcomes.
