Ebenezer
Clinical Documentation Integrity Specialist
Ebenezer, Saint Paul, Minnesota, United States, 55199
Job Overview
Fairview is looking for a Clinical Documentation Integrity Specialist to join our team. The CDI Specialist performs concurrent inpatient chart reviews for documentation improvement opportunities. Communicates with physicians to facilitate comprehensive medical record documentation to reflect clinical treatment and diagnoses, uses hospital's CDI software to identify opportunities, evaluates documentation on a day‑to‑day basis, gathers and analyzes information pertinent to findings and outcomes, arranges formal and informal education sessions for all providers, formulates a DRG and confers with coders to ensure appropriate DRG. This review process assures the quality of the documentation used for patient care, regulatory compliance, and reimbursement.
Position Details
1.0 FTE (80 hours per pay period)
day shift
no weekends
fully remote, salaried position
Responsibilities
Completes a concurrent review of the medical record for assigned patients in the required timeframe.
Performs daily case reviews and identifies diagnoses and procedures in order to assign in accurate working DRG. Performs follow‑up medical record reviews to identify any additional diagnoses or procedures that may impact the DRG assignment. Confers with coders to ensure appropriate final DRG and completeness of supporting documentation.
Develops physician education strategies to promote complete and accurate clinical documentation and correct negative trends. Confers with nursing, case management, utilization review and other clinical caregivers to explain the importance of clear and concise documentation.
Collects and analyzes data showing the activities performed, results of interactions, improvements made in clinical documentation, and distribution of DRGs and case mix index.
Organization Expectations, as applicable:
Demonstrates ability to provide care or service adjusting approaches to reflect developmental level and cultural differences of population served
Partners with patient care giver in care/decision making.
Communicates in a respective manner.
Ensures a safe, secure environment.
Individualizes plan of care to meet patient needs.
Modifies clinical interventions based on population served.
Provides patient education based on an assessment of learning needs of patient/care giver.
Fulfills all organizational requirements
Completes all required learning relevant to the role
Complies with and maintains knowledge of all relevant laws, regulation, policies, procedures and standards.
Fosters a culture of improvement, efficiency and innovative thinking.
Performs other duties as assigned
Required Qualifications
Associates Degree in Nursing or Health Information Management (HIM) degree or related field or equivalent experience
2 years Acute/Inpatient experience as an RN or
5 years inpatient coding experience
Knowledge of clinical documentation requirements related to regulatory and reimbursement rules and regulations
Knowledge of current coding and DRG classification systems
Knowledge of medical terminology, anatomy and pathophysiology, pharmacology, ancillary test results
Knowledge of ICD-10-CM and DRG classification systems
Knowledge of physician and nursing unit practices
Excellent interpersonal, critical thinking and conflict management skills
Computer and data analysis skills" does not add
Excellent verbal and written communication and presentation skills
Analytical Thinking: Ability to identify issues, obtain relevant information, relate and compare data from different sources and identify alternative solutions
Attention to detail: Achieve thoroughness and accuracy when accomplishing a task
Critical Thinking: Gathers and integrates critical information, recognizing and addressing underlying assumptions of others to arrive at effective solutions
Medical Staff Relations: Builds effective partnerships with medical staff, physicians, fostering open lines of communications and establishing trust
Problem Solving: Identifies problems, determines accuracy and relevance of information, utilizes appropriate tools and staff resources along with sound judgment to generate and evaluate alternatives and to make recommendations
Written Communication: Ability to organize and express information and ideas in written form to individuals as well as groups. Constructs messages that are clear and convincing
Registered Nurse of MN Upon Hire or
current Registered Health Information Administrator (RHIA) MN Board of Nursing or American Health Information Management Association Upon Hire or
Registered Health Information Tech (RHIT) MN Board of Nursing or American Health Information Management Association Upon Hire
Preferred Qualifications
Bachelors Degree in Nursing for candidate’s with nursing experience
5 years acute care nursing or
5 years inpatient coding experience
Certified Clinical Documentation Specialist (CCDS) for candidate’s with HIM experience American Health Information Management Association Upon Hire
Benefit Overview Fairview offers a generous benefit package including but not limited to medical, dental, vision plans, life insurance, short‑term and long‑term disability insurance, PTO and Sick and Safe Time, tuition reimbursement, retirement, early access to earned wages, and more! Please follow this link for additional information: https://www.fairview.org/careers/benefits/noncontract
Compensation Disclaimer The posted pay range is for a 40‑hour workweek (1.0 FTE). The actual rate of pay offered within this range may depend on several factors, such as FTE, skills, knowledge, relevant education, experience, and market conditions. Additionally, our organization values pay equity and considers the internal equity of our team when making any offer. Hiring at the maximum of the range is not typical. If your role is eligible for a sign‑on bonus, the bonus program that is approved and in place at the time of offer, is what will be honored.
EEO Statement EEO/Vet/Disabled: All qualified applicants will receive consideration without regard to any lawfully protected status$80,100.80- $113,068.80 Annual
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Position Details
1.0 FTE (80 hours per pay period)
day shift
no weekends
fully remote, salaried position
Responsibilities
Completes a concurrent review of the medical record for assigned patients in the required timeframe.
Performs daily case reviews and identifies diagnoses and procedures in order to assign in accurate working DRG. Performs follow‑up medical record reviews to identify any additional diagnoses or procedures that may impact the DRG assignment. Confers with coders to ensure appropriate final DRG and completeness of supporting documentation.
Develops physician education strategies to promote complete and accurate clinical documentation and correct negative trends. Confers with nursing, case management, utilization review and other clinical caregivers to explain the importance of clear and concise documentation.
Collects and analyzes data showing the activities performed, results of interactions, improvements made in clinical documentation, and distribution of DRGs and case mix index.
Organization Expectations, as applicable:
Demonstrates ability to provide care or service adjusting approaches to reflect developmental level and cultural differences of population served
Partners with patient care giver in care/decision making.
Communicates in a respective manner.
Ensures a safe, secure environment.
Individualizes plan of care to meet patient needs.
Modifies clinical interventions based on population served.
Provides patient education based on an assessment of learning needs of patient/care giver.
Fulfills all organizational requirements
Completes all required learning relevant to the role
Complies with and maintains knowledge of all relevant laws, regulation, policies, procedures and standards.
Fosters a culture of improvement, efficiency and innovative thinking.
Performs other duties as assigned
Required Qualifications
Associates Degree in Nursing or Health Information Management (HIM) degree or related field or equivalent experience
2 years Acute/Inpatient experience as an RN or
5 years inpatient coding experience
Knowledge of clinical documentation requirements related to regulatory and reimbursement rules and regulations
Knowledge of current coding and DRG classification systems
Knowledge of medical terminology, anatomy and pathophysiology, pharmacology, ancillary test results
Knowledge of ICD-10-CM and DRG classification systems
Knowledge of physician and nursing unit practices
Excellent interpersonal, critical thinking and conflict management skills
Computer and data analysis skills" does not add
Excellent verbal and written communication and presentation skills
Analytical Thinking: Ability to identify issues, obtain relevant information, relate and compare data from different sources and identify alternative solutions
Attention to detail: Achieve thoroughness and accuracy when accomplishing a task
Critical Thinking: Gathers and integrates critical information, recognizing and addressing underlying assumptions of others to arrive at effective solutions
Medical Staff Relations: Builds effective partnerships with medical staff, physicians, fostering open lines of communications and establishing trust
Problem Solving: Identifies problems, determines accuracy and relevance of information, utilizes appropriate tools and staff resources along with sound judgment to generate and evaluate alternatives and to make recommendations
Written Communication: Ability to organize and express information and ideas in written form to individuals as well as groups. Constructs messages that are clear and convincing
Registered Nurse of MN Upon Hire or
current Registered Health Information Administrator (RHIA) MN Board of Nursing or American Health Information Management Association Upon Hire or
Registered Health Information Tech (RHIT) MN Board of Nursing or American Health Information Management Association Upon Hire
Preferred Qualifications
Bachelors Degree in Nursing for candidate’s with nursing experience
5 years acute care nursing or
5 years inpatient coding experience
Certified Clinical Documentation Specialist (CCDS) for candidate’s with HIM experience American Health Information Management Association Upon Hire
Benefit Overview Fairview offers a generous benefit package including but not limited to medical, dental, vision plans, life insurance, short‑term and long‑term disability insurance, PTO and Sick and Safe Time, tuition reimbursement, retirement, early access to earned wages, and more! Please follow this link for additional information: https://www.fairview.org/careers/benefits/noncontract
Compensation Disclaimer The posted pay range is for a 40‑hour workweek (1.0 FTE). The actual rate of pay offered within this range may depend on several factors, such as FTE, skills, knowledge, relevant education, experience, and market conditions. Additionally, our organization values pay equity and considers the internal equity of our team when making any offer. Hiring at the maximum of the range is not typical. If your role is eligible for a sign‑on bonus, the bonus program that is approved and in place at the time of offer, is what will be honored.
EEO Statement EEO/Vet/Disabled: All qualified applicants will receive consideration without regard to any lawfully protected status$80,100.80- $113,068.80 Annual
#J-18808-Ljbffr