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Provides one-on-one and classroom clinical documentation and coding education to Clinical Documentation Integrity (CDI) specialists, medical staff, midlevel providers and others. Functions as a subject matter expert for CCHS regarding documentation, reimbursement and data interpretation as it relates to inpatient records. Conducts the quality review of inpatient CDI cases, queries, assigned codes and working DRG. Participates in process improvement activities based on audit results. Participates in hospital or institute performance Improvement projects impacted by documentation.Responsibilities:Educates and mentors new employees through the on-boarding process.
Provides classroom and one-on-one training for CDI staff including initial CDI process and concept training and on-going education related to new topics in CDI, coding and reimbursement.
Supports CDS with new technology and technology updates.
Assists with and/or provides suggestions for continuing education topics and issues for CDI staff.
Monitors CDI compliance through quality audits and data analysis. Provides feedback to the CDI management team and staff regarding ICD-9-CM or ICD 10 CM/PCS coding, DRG assignment and related clinical documentation issues or concerns.
Analyzes and evaluates clinical and operational systems and processes relative to inpatient reimbursement and quality statistics through chart review and other special study methods. Makes recommendations for data quality improvements and revenue enhancements.
Develops and maintains CCHS facilities CDI policies and guidelines in accordance with AHIMA Practice Briefs, Official Coding Guidelines, ACDIS standards and Coding Clinic.
Educates groups and individuals within and external to HIM regarding documentation, coding, DRG, ICD code assignment, and the reimbursement process. Interacts with and educates physicians and mid-level providers in group settings or one-on-one.
Assists with the analysis of CDIS reports and other statistical reports.
Provides assistance with CDI Specialist responsibilities as workload permits.
Supports CDI program initiatives.
Promotes good morale and cooperation.
Encourages others and values their input.
Shares information and seeks ways to add value both to the customer and to the team.
Anticipates and responds to changing skills requirements.
Seeks opportunities to learn new skills. Actively coaches and encourages team members to do the same.
Successfully integrates team into the CDI process to promote their development.
Complies with CCHS and departmental policies and procedures consistently.
Other duties as assigned.
Education:Must meet one of the following education requirements: An Associate's Degree in Health Information Management from a CAHIM accredited program or related field or a Bachelor's Degree in Health Information Management from a Commission on Accreditation for Health Informatics and Information Management (CAHIIM) accredited program or related field or a graduate from an accredited school of nursing (Licensed Practical Nurse or Registered Nurse); or graduate of a medical college.
Formal coursework in anatomy, physiology and medical terminology in order to accurately interpret the medical record.
Certifications:Graduates from an accredited school of nursing must have an active State of Ohio Licensed Practical Nurse (LPN) or Registered Nurse (RN) licensure.
Individuals with an Associate's Degree in Health Information Management must be a Registered Health Information Technician (RHIT).
Individuals with a Bachelor's Degree in Health Information Management must be a Registered Health Information Administrator (RHIA).
Individuals with medical doctor degree do not need to maintain a medical license.
Certified Documentation Improvement Practitioner (CDIP), Certified Clinical Documentation Specialist (CCDS) or Certified Coding Specialist (CCS) preferred.
Complexity of Work:Requires critical thinking skills, decisive judgment and the ability to work with minimal supervision.
Must be able to work in a stressful environment and take appropriate action.
Must have expert knowledge of CDIS application.
Working knowledge of both personal computer applications and mainframe computer systems.
Excellent verbal and written communications.
Must be detail oriented and analytical in nature.
In-depth knowledge of ICD-9-CM (ICD-10-CM) coding principles and DRG assignment.
Work Experience:Three years of experience in a clinical documentation improvement in and inpatient setting.
A Bachelor's Degree in Nursing or medical degree may substitute for up to two years of required experience.
Personal Protective Equipment:Follows Standard Precautions using personal protective equipment as required for procedures.
The policy of Cleveland Clinic Health System and its system hospitals (Cleveland Clinic Health System) is to provide equal opportunity to all of our employees and applicants for employment in our tobacco free and drug free environment. All offers of employment are followed by testing for controlled substance and nicotine. Job offers will be rescinded for candidates for employment who test positive for nicotine. Candidates for employment who are impacted by Cleveland Clinic Health System's Smoking Policy will be permitted to reapply for open positions after 90 days.Decisions concerning employment, transfers and promotions are made upon the basis of the best qualified candidate without regard to color, race, religion, national origin, age, sex, sexual orientation, marital status, ancestry, status as a disabled or Vietnam era veteran or any other characteristic protected by law. Information provided on this application may be shared with any Cleveland Clinic Health System facility.Please review the Equal Employment Opportunity posterCleveland Clinic Health System is pleased to be an equal employment employer: Women / Minorities / Veterans / Individuals with DisabilitiesCleveland Clinic is pleased to be an equal employment/affirmative action employer: Women/Minorities/Veterans/Individuals with Disabilities.
Full-time