Under the general supervision of the Supervisor, Clinical Documentation Improvement the Clinical Documentation Improvement Specialist (CDIS) facilitates and obtains appropriate physician documentation for any clinical conditions or procedures which support the appropriate severity of illness, expected risk of mortality and the complexity of care of the patient population. This individual exhibits a sufficient knowledge of clinical documentation requirements, DRG assignment, and clinical conditions and procedures for the pediatric patient population. This individual also educates members of the patient care team regarding documentation guidelines, including attending physicians, allied health practitioners, nursing staff, and case management.
Essential Duties and Responsibilities:
- Completes initial and subsequent concurrent reviews of pediatric inpatient medical records in accordance with established timelines, in order to promote accurate code and DRG assignment and assessment of risk of mortality and severity of illness.
- Queries physicians regarding missing, unclear, or conflicting health record documentation by requesting and obtaining additional documentation in the health record when needed.
- Collaborates with case managers, nursing staff, and other ancillary staff regarding interaction with physicians on documentation issues and strives to resolve physician queries prior to patient discharge.
- Reviews and clarifies clinical issues in the health record with the coding professionals to support accurate DRG assignment, severity of illness, and/or risk of mortality.
- Educates physicians and key healthcare providers regarding clinical documentation improvement and the need for accurate and complete documentation in the health record.
- Supports and participates in the continuous assessment and improvement of the quality of services provided.
- Participates in the analysis and trending of statistical data for specified patient populations to identify opportunities for improvement
- Assists with preparation and presentation of clinical documentation monitoring/trending reports for review with physicians and hospital leadership
- Educates members of the patient care team regarding specific documentation needs and reporting and reimbursement issues identified through daily and retrospective documentation reviews and aggregate data analysis.
Required Licenses, Certifications, Registrations
- Adheres to established departmental policies, procedures, and objectives.
- Enhances professional growth and development by accessing educational programs, job related literature, in-service meetings, and workshops/seminars.
- Enhances professional growth and development through participation in educational programs, current literature, in-service meetings and workshops.
- Maintains established department/hospital/system policies and procedures, directives, safety, environmental and infection control standards apprpriate to this position.
- Demonstrates a courteous and professional manner through interactions with internal and external customers.
- Integrates scientific principles and research based knowledge in decision making.
- Exemplifies a professional image in appearance, manner and presentation.
- Engages in self-performance appraisal, identifying areas of strength as well as areas for professional development.
- Researches, selects and promotes adaptation of best practice findings to ensure quality patient care and optimal outcomes.
- Adapts behavior as needed to the specific patient population, including but not limited to: respect for privacy, method of introduction to the patient, adapting explanation of services or procedures to be performed, requesting permissions and communication style
- Performs other related duties as assigned.
Registered Nursing License in the Commonwealth of Pennsylvania or State of New Jersey, depending on the assigned work location.Required Education and Experience
Required Education: Associate’s Degree in Nursing
Required Experience: Three (3) years acute care nursing experience (e.g., ED, ICU, case management, etc.)
Preferred Education, Experience & Cert/Lic
Preferred Education: BSN
Additional Technical Requirements
- Three (3) years acute care pediatric nursing experience (e.g., ED, ICU, case management, etc.) preferred will consider translatable adult acute care experience.
- Two (2) years’ experience as a CDIS
- Ability to work effectively with all departments and all levels of CHOP professionals.
- Ability to work independently or within a team structure.
- Must be very organized and able to work independently.
- Ability to establish priorities among multiple needs, meet deadlines and maintain standards of productivity.
- Computer skills and a working knowledge of Word, Excel and Access.
- Strong knowledge base in complete and accurate clinical documentation in the acute care setting and for all healthcare disciplines.
- Strong knowledge base and experience in interpreting and applying federal/government regulations to ensure coding and documentation compliance
- Strong knowledge base of the conventions, rules and guidelines for multiple classification and reimbursement systems (i.e. ICD -10, DRGs, APR-DRGs, etc).
- Ability to establish rapport with physicians and other healthcare practitioners.
- Demonstrated knowledge of medical terminology, anatomy and physiology, pharmacology, computers, and encoding software.
- Demonstrated interpersonal, critical thinking, and time management skills.
- Strong communication, teaching and presentation skills; must be detail oriented, and possess good problem solving skills