Clinical Document Integrity Specialist

• Matching 401(k)/403(b) Plans

• Excellent Health, Dental, and Vision

• Disability and Life Insurance options

• On Site Child Care

• Educational Reimbursement

• Health Care and Dependent Care Flex Spending Accounts

• Plus, an array of Voluntary Benefits to include Critical Care Coverage and more!

• Location: Kent Campus Hospital, Dover Delaware
• Status: Part Time 48 Hours Biweekly
• Shift: Days

Salary range: 37.07 - 57.47 hourly

Note: Requires an RN License, a minimum of an Associates Degree in Nursing and 5 years acute care experience in med surg or critical care.

General

Summary

An RN who is responsible for the evaluation of physician documentation utilizing their clinical expertise to ensure the patients’ severity of illness is accurately portrayed in the medical record for specificity of coding and increased coding accuracy. They provide guidance to the physicians, nursing, and ancillary staff on clinical documentation best practices.

Responsibilities

• Completes initial / admission reviews of patient records for a specified patient population to: a) evaluate documentation to assign the principal diagnosis, pertinent secondary diagnoses, and procedures for accurate DRG assignment, right of mortality, and severity of illness; and b) initiate a query worksheet if clarification is needed.

• Demonstrates knowledge of DRG payor issues, documentation opportunities, clinical documentation requirements, and referral policies and procedures.

• Conducts follow-up reviews every 1-2 days of clinical documentation to ensure points of clarification have been recorded in the patient’s chart. Ensures the accuracy and completeness of clinical information used for measuring and reporting physician and medical center outcomes.

• Collaborates and educates members of the healthcare team regarding specific documentation needs and reporting and reimbursement issues identified through daily concurrent reviews and aggregate data analysis.

• Accuracy is confirmed between the CDIS and the coding professional through reconciliation of the working DRG and final DRG.

• Educates all internal customers on compliant documentation opportunities, coding, and reimbursement issues, as well as performance improvement methodologies. Reviews clinical issues with coding staff to assign a working DRG.

• Collaborates with the healthcare team keeping them aware of the Geometric Mean Length of Stay (GMLOS) associated with the working DRG. Documents the GMLOS in the patient chart, nursing unit, and on the communication board in the patient room.

• Maintain productivity standard of a minimum of 20 reviews to produce 5 queries per day.

• All other duties as assigned, within the scope and range of job responsibilities.

Required Education, Credential(s) and

Experience

Education

• Associate Degree Nursing

;

• Credential(s):

• Registered Nurse

;

Experience

• Required: 5 years acute-care experience in Med/Surg and or Critical Care. Preferred: Utilization Review, Case Management and/or coding experience.

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