The System Clinical Documentation Improvement (CDI) Quality Specialist position is responsible for performing internal quality assurance reviews and provide on-going education to Clinical Documentation Specialist (CDS) staff to ensure compliance with national guidelines and policies for complete, accurate and consistent reporting which results in appropriate reimbursement and data integrity. This position reviews outcomes that are communicated to the team through various modes of education to improve the accuracy, integrity and quality of patient data, to ensure minimal variation in practices and to improve the quality of physician documentation within the body of the medical record to support code assignments. The CDI Quality Specialist provides onboarding training for new staff and education, based on quality reviews or existing staff. This position promotes a partnership between the concurrent clinical reviewers, medical record coders, and physicians to improve documentation and reimbursement.
FLSA STATUSExempt
QUALIFICATIONSEDUCATION- Bachelor's degree from an accredited school of nursing
- Master of Science in Nursing or other master's degree in a related field preferred
EXPERIENCE- Three years of recent clinical documentation experience in an acute care hospital
- Academic hospital experience and coding experience preferred
LICENSES AND CERTIFICATIONSRequired- RN - Registered Nurse - Texas State Licensure - Texas Board of Nursing_PSV Compact Licensure - Must obtain permanent Texas license within 60 days (if establishing Texas residency)
Preferred- CCS - Certified Coding Specialist (AHIMA) or
- CCDS - Clinical Documentation Specialists (ACDIS) or
- CDIP - Certified Documentation Integrity Practitioner (AHIMA)
SKILLS AND ABILITIES- Demonstrates the skills and competencies necessary to safely perform the assigned job, determined through ongoing skills, competency assessments, and performance evaluations
- Sufficient proficiency in speaking, reading, and writing the English language necessary to perform the essential functions of this job, especially with regard to activities impacting patient or employee safety or security
- Ability to effectively communicate with patients, physicians, family members and co-workers in a manner consistent with a customer service focus and application of positive language principles
- Demonstrates knowledge of DRG payor issues, appropriate DRG assignment alternatives, clinical documentation requirements, and referral policies and procedures
- Demonstrates knowledge of education modalities to enhance the way staff receive, process, and retain information in a learning environment
- Demonstrates accountability and professional development
- Requires excellent observation skills, analytical thinking, problem solving, plus good verbal and written communication
- Ability to interact and maintain regular significant contacts with other personnel throughout the institution (including but not limited to - physicians and their staff, mid-level providers, mid-level staff, coders, Case Managers); contacts methods may be in person, by telephone, or through correspondence
- Ability to display assertiveness while being even tempered, with a pleasing personality and the ability to communicate easily with others
- Working knowledge of Microsoft products including PowerPoint, Word, Excel and Outlook
ESSENTIAL FUNCTIONSPEOPLE ESSENTIAL FUNCTIONS- Acts as documentation liaison with Health Information Management, Case Management, ancillary departments, physicians, staff, and management.
- Assists in ensuring Clinical Documentation Specialists (CDS) adherence with clinical documentation and coding guidelines and policies.
- Supports new and existing CDI staff development through training and education based on individual CDI staff needs.
SERVICE ESSENTIAL FUNCTIONS- Serves as subject matter expert and clinical resource for CDS and coding staff to clarify and interpret medical record documentation for complete and accurate coding and DRG assignment.
- Interacts and communicates with physicians and other providers as needed, educating them in the process of clarifying documentation in the medical record.
QUALITY/SAFETY ESSENTIAL FUNCTIONS- Ensures/Performs ongoing Quality Assurance reviews on each CDS based on Department Policies and Procedures and CDS Job Description, utilizing Training Manual, ICD-10-CM/PCS Coding Volumes, Coding Clinic, DRG Expert, AHIMA Compliant Query Guidelines and any other relevant sources and reports findings to leadership and staff.
- Evaluates the monitoring tools and applies action plans specific to the outcomes to improve the program.
- Supports the accuracy and completeness of clinical information used for measuring and reporting physician and hospital outcomes.
- Identifies special reviews or projects for review and clinical documentation improvement.
- Delivers education to ensure program quality standards are met.
FINANCE ESSENTIAL FUNCTIONS- Promotes clarification of clinical documentation, advocating for appropriate reimbursement for the patient care resources consumed and the level of service rendered.
GROWTH/INNOVATION ESSENTIAL FUNCTIONS- Generates and communicates new ideas and suggestions that improve quality, service, or finance.
- Maintains and applies up-to-date knowledge of official clinical documentation and coding guidelines, policies and procedures, and clinical/medical resources to assure knowledge and skills remain current.
- Develops and maintains comprehensive education programs for staff at all skill levels to enhance individual CDS knowledge.
- Makes recommendations for resources and tools to support education program.
SUPPLEMENTAL REQUIREMENTSWORK ATTIRE- Uniform: No
- Scrubs: No
- Business professional: Yes
- Other (department approved): Yes
ON-CALL*
*Note that employees may be required to be on-call during emergencies (ie. Disaster, Severe Weather Events, etc) regardless of selection below.
TRAVEL**
**Travel specifications may vary by department**- May require travel within the Houston Metropolitan area No
- May require travel outside Houston Metropolitan area No
Work Shift:
1 - Day (United States of America)
Job Category:
Non-clinical
