Job Description

Work Schedule

Monday-Friday 8:00 AM-5:00 PM

Work Location

Virtual: Remote work for TX, AR, WI and FL (not Miami-Dade county) ONLY

Primary Purpose

The Clinical Documentation Integrity Specialist (CDIS) applies clinical knowledge to analyze and to interpret health records. Proficiently applies ICD-10, CPT, SOI/ROM coding to in-house patients. Analyzes records for optimization of physician documentation and query potential, if required. Provides education to providers, coders, case management and interacts with other departments as required. Tracks pre and post DRG data. Performs varied, difficult, and specialized tasks without detailed guidance, is expected to exercise judgment and apply expert knowledge.

Education

• Must have a degree in nursing from an accredited college or university.

–OR–

• Master’s Degree in a Healthcare/Medical related field from an U.S. accredited college or university

–OR–

• Graduated from an accredited Health Information Management coding program

Experience

• For RNs: Three plus (3+) years of clinical experience in an acute care setting (ICU/Critical Care / Surgery Specialty)
• For HIM Professionals: Must have two plus (2+) years of inpatient coding experience working with the coding classification systems, medical terminology, anatomy and physiology and disease processes.
• RN/HIM Professionals must have Two plus (2+) years of experience working in clinical documentation integrity

Equivalent Education and/or Experience

• May have an equivalent combination of education and experience to substitute for both the education and the experience requirements.

Certification/Registration/Licensure

• Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Integrity Practitioner (CDIP) certification is required.

Skills or Special Abilities

• Organizational, analytical, writing and interpersonal skills.
• Must be able to be comfortable speaking and teaching in group settings
• Must possess expert knowledge of medical terminology, anatomy & physiology and ICD-10 and CPT coding principles.
• Must be able to communicate effectively with physicians, nursing and ancillary staff.
• Must be able to demonstrate patient centered/patient valued behaviors.
• Must demonstrate knowledge and skill in age specific needs and the elements of disease processes and related procedures.
• Must have knowledge of ICD-10-CM and ICD-10-CM/PCS coding conventions and/or clinical auditing processes.
• Must be able to demonstrate a working knowledge of MS Office software, including Word, Excel, and PowerPoint.
• For RN applicants:
• RN applicants must maintain standards of professional conduct and performs all assigned and unassiged duties in accordance with the current State of Texas Nurse Practice Act.

Responsibilities

• Collaborates with physician, physician extender, nurse, case manager/utilization reviewer and HIM coder to identify principal diagnosis options, secondary diagnoses and procedures, to assign working MS-DRGs and or APR-DRG for at least 95% of identified populations.
• Conducts initial and extended-stay concurrent reviews on all selected inpatient admissions and documents findings within 3M CDIS software.
• Identifies need to clarify documentation in records and utilizes strong communication skills with physician, physician extender, nurse or other healthcare professionals, utilizing appropriate tools to capture needed documentation. Works collaboratively with the healthcare team to facilitate documentation within the medical record that supports patient's severity of illness and risk of mortality.
• Assists in the development of query response physician reports. Maintains complete confidentiality of patient information, in addition to hospital and individual physician practice pattern data.
• Provides information and in-services as necessary to physician and ancillary staff.
• This position is 100% Virtual. Virtual employees must also comply with all Parkland policies and procedures governing the use of Parkland information resources. Virtual employees must maintain all equipment lent by Parkland for performing the agreed upon job duties in good working conditions. All employment responsibilities and conditions in applicable Parkland policies and procedures apply to employees while working virtually.

Job Accountabilities

• Identifies ways to improve work processes and improve customer satisfaction. Makes recommendations to supervisor, implements, and monitors results as appropriate in support of the overall goals of the department and Parkland.
• Stays abreast of the latest developments, advancements, and trends in the field by attending seminars/workshops, reading professional journals, actively participating in professional organizations, and/or maintaining certification or licensure. Integrates knowledge gained into current work practices.
• Maintains knowledge of applicable rules, regulations, policies, laws and guidelines that impact the area. Develops effective internal controls designed to promote adherence with applicable laws, accreditation agency requirements, and federal, state, and private health plans. Seeks advice and guidance as needed to ensure proper understanding.