Job Description

Reporting to the Manager of CDI, this individual is responsible to identify physician documentation improvement opportunities, ensuring all relevant information is included and accurately reflects the patient’s condition and care. Works closely with physicians and other healthcare providers to clarify documentation and address any discrepancies and/or ambiguities. Participates in continuous close collaboration with the hospital Inpatient Coding team and other on related workflows. Remains current with the latest coding guidelines and documentation standards. Supports the overall success of the CDI program.

• Provides review of medical records to facilitate appropriate physician documentation of clinical conditions and procedures. -20%
  
• Analyze medical records to support appropriate severity of illness, expected risk of mortality, complexity of care for the patient, Present on Admission indicator(s), quality measures (Hospital Acquired Conditions, Patient Safety Indicators, etc.), and other focus areas as needed and where applicable. -20%
  
• Maintains knowledge of ICD-10 diagnosis and PCS procedure coding, MS and APRDRG assignments, clinical conditions, and documentation practices. -5%
  
• Educates members of the patient care team regarding documentation guidelines, including physicians and extenders, and clinical service areas when appropriate. -10%
  
• Helps ensure timeliness of all written and verbal queries from providers to ensure proper documentation is obtained and placed in the medical record prior to the patient’s discharge, and post discharge if requested by the Inpatient Coding team. -20%
  
• Maintains communication with providers as necessary to help ensure timely, complete and accurate medical record documentation. -5%
  
• Communicates with coworkers in an open and respectful manner that promotes knowledge sharing and teamwork by way of electronic messaging, video and telephone conferencing and in person as needed. -5%
  
• Follows the United States Department of Health and Human Services (USDHHS) ICD-10-CM Official Guidelines for Coding and Reporting. -5%
  
• Follows standards of ethical coding and coding interpretive guidelines set forth by AHIMA, ACDIS and the AHA Coding Clinic and other regulatory references as applicable. -5%
  
• Performs other job-related duties as assigned.
  

Education and/or Experience Required:

• Education: Bachelors in Nursing (BSN).
• Experience: Minimum of 3 years of pediatric clinical experience required.
• At least one year of experience as a Clinical Documentation Integrity Specialist.

Education and/or Experience Preferred:

• Experience:
  • Previous UR/CDI, case management or care coordination preferred.
  • 5 years of nursing experience in either Med/Surg, Intensive Care, additional Pediatric and NICU experience preferred.
  • 1 year of experience in Clinical Documentation Integrity

License and/or Certification Required:

• Registered Nurse (RN).
• Holds a recognized credential from ACDIS (CCDS) or AHIMA (CDIP), AHIMA (CCS), or is willing to secure this credential within the first year of hire.

License and/or Certification Preferred:

• CCDS and CCS or, CDIS and CCS, or CDIS, CCDS, CCS.

Knowledge, Skills and Abilities:

Knowledge:

• Self-motivated, strong organizational skills, excellent speaking and presentation skills.
• Willingness to update technical expertise and to develop management/leadership skills through continuing education throughout tenure in position.

Skills:

• Strong interpersonal and communication skills to manage competing priorities of the different stakeholders to ensure provision of high quality, high value and efficient care.
• Electronic medical record knowledge and use.
• Utilizes applicable electronic system(s) supporting job functions.

Abilities:

• Learn/develop the skills necessary to perform Clinical Documentation review of medical records.
• Understand and communicate the impact of CC/MCC’s and other variables on the assignment of the various DRG methodologies.
• Handle multiple priorities and increasing responsibility.
• Collaborate with others to achieve a common goal through mutual cooperation.
• Influence others for positive and productive outcomes.
• Quickly process complex problems, identify key components, and develop plans for resolution.
• Able to understand and utilize necessary computer systems.
  

Connecticut Children’s is the only health system in Connecticut that is 100% dedicated to children. Established on a legacy that spans more than 100 years, Connecticut Children’s offers personalized medical care in more than 30 pediatric specialties across Connecticut and in two other states. Our transformational growth establishes us as a destination for specialized medicine and enables us to reach more children in locations that are closer to home. Our breakthrough research, superior education and training, innovative community partnerships, and commitment to diversity, equity and inclusion provide a welcoming and inspiring environment for our patients, families and team members.

At Connecticut Children’s, treating children isn’t just our job – it’s our passion. As a leading children’s health system experiencing steady growth, we’re excited to expand our team with exceptional team members who share our vision of transforming children’s health and well-being as one team.