Clinical Documentation Improvement Specialist – Remote Position Available In Fulton, Georgia

Clinical Documentation Improvement Specialist – Remote Pyramid Consulting Atlanta, GA Job Details Contract $55 an hour 5 hours ago Qualifications Doctor of Medicine Nursing Medicine Management Inpatient Doctoral degree RN License Bachelor of Science CDIP Qualitative analysis Master’s degree ICU experience High school diploma or

GED ICD-10

Analysis skills Project management Bachelor’s degree Case management Master of Science Master of Nursing Patient care Bachelor of Science in Nursing Discharge planning MSN Clinical documentation improvement Epic Quantitative analysis CCDS Senior level Leadership 2 years Adult learning Documentation review Communication skills Physician Assistant License DRG Time management Full Job Description Job description:

Job Summary:

This position requires a high level of professional clinical knowledge and knowledge of coding guidelines and documentation requirements to identify and query for documentation improvement. This documentation clarification improves overall patient quality, as well as maximizes the capture and reflection of the acuity of the patient. Through essential and effective communication with physicians and ancillary clinical providers, accurate classification of the severity of illness and risk of mortality level of the patient is achieved. This position works within a multidisciplinary professional team to achieve desired documentation outcomes at the facility level.

Essential Responsibilities:

Effective and efficient inpatient concurrent medical record review for accurate and complete documentation, within an electronic medical record environment. Reviews clinical cases in collaboration with medical coding staff and physicians, to identify additional diagnoses that impact severity of illness/risk of mortality indicators for each patient. Manages and prioritizes numerous cases on a daily basis. Manages cases at the facility level, using flexibility to provide coverage for any NCAL facility, based on staffing need, as determined by census, on a daily basis. Facilitates appropriate clinical documentation to support diagnosis capture and to ensure the level of service rendered to all patients is accurately recorded and reflected. Provides expert analysis of the medical record documentation for signs/symptoms/clinical indicators, to identify potential primary and secondary diagnoses and complications existing within each patient case. Formulates and distributes physician documentation clarification queries following coding guidelines and all applicable compliance standards. Creates, monitors and tracks verbal and written queries, responses and their impact; producing reports as required. Identifies documentation trends, and areas of opportunity for physician education regarding documentation. Conducts data and root cause analysis, provides feedback and shares findings on the analysis to regional CDI Leadership. Collaborates with TPMG contacts and CDI staff and Leadership in the development of programs which provide alignment with education for internal customers to support clinical documentation guidelines. Leads special projects/committees that contribute to the development of an effective CDI program. Collaborates and communicates with local HIM staff and local HIM leadership to ensure accurate documentation capture. Effectively communicates with local coding staff regarding query responses, to assist with the efficiency and completeness of the medical record of the post-discharge physician query process. Provides feedback and serves as clinical expert resource to CDIC QA staff. Provides expert advice to CDI Regional Managers to develop, implement and monitor policies and procedures that support organizational goals and business objectives related to the CDI Program. Adheres to organizational standards to promote a cooperative work environment by utilizing professional communication skills. Collaborates effectively with coding professionals, nursing and clinical experts, ancillary services, physicians and administration. Establishes, fosters and maintains effective working relationships with the local and regional staff/teams/leadership. Client’s conducts compensation reviews of positions on a routine basis. At any time, Client’s reserves the right to reevaluate and change job descriptions, or to change such positions from salaried to hourly pay status. Such changes are generally implemented only after notice is given to affected employees.

Basic Qualifications:

Experience:

Minimum four (4) years of clinical nursing experience (i.e. Inpatient, clinical documentation, discharge planning or case management).

Education:

Bachelor’s degree OR four (4) years of experience in a directly related field (i.e. Inpatient, clinical documentation, discharge planning or case management). High School Diploma or General Education Development (GED) required. License, Certification, Registration Physician Assistant License (California) OR Doctor of Medicine License (Foreign Country) OR Doctor of Medicine License (California) OR Registered Nurse License (California)

Additional Requirements:

RN, NP, PA or MD may qualify depending on background and experience. Ability to utilize clinical knowledge to interpret physician documentation and clinical indicators to identify potential opportunities for documentation clarification/specification. Demonstrated ability to work in an autonomous work environment. Strong interpersonal, communication (verbal, non-verbal, and listening skills). Demonstrated ability to conduct and interpret quantitative/qualitative analysis. Proven leadership skills in project management and/or consulting. Must exhibit efficiency, collaboration, Candor, and openness and results orientation. Understanding of Adult Learning Theory. Application of Adult Learning Theory to orientation and training of new hires. Understanding of how to perform and achieve success in a data driven environment. Excellent time management and prioritization skills. Must be able to work in a Labor/Management Partnership environment.

Preferred Qualifications:

Experience working with an electronic health record (Epic) Experience working with 3M Encoder Knowledge of and experience with Hierarchical Condition Categories (HCCs) Clinical experience in Intensive Care patient care experience preferred. Minimum 2 years Clinical Documentation Integrity or Improvement experience Minimum 3 yrs inpatient clinical patient care experience Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Professional (CDIP) preferred. Experience with chart review and/or auditing preferred (i.e. utilization management, case management, discharge planning, etc.). Experience/working knowledge of Coding Classification Systems (current ICD-CM classification, MS-DRGs, HCCs) and payment methodologies preferred. Clinician Documentation Integrity/improvement (CDI) experience preferred. Certified Clinical Documentation Specialist (CCDS) OR Certified Documentation Improvement Practitioner (CDIP) Certification preferred. Bachelor’s degree of Science in Nursing (BSN), Master of Science in Nursing (MSN), Master of Science (MS) with Nurse Practitioner or Physician Assistant License, MBS (Bachelor of Science in Medicine), or Doctor of Medicine (MD) preferred

Job Type:

Contract Pay:

$55.00 per hour Expected hours: 40 per week

Schedule:

8 hour shift Day shift Monday to

Friday Work Location:

Remote