Job Summary

The Senior Clinical Documentation Improvement Specialist (SDIS) is responsible for coordinating the CDIS team while performing CDIS responsibilities. The Senior Clinical Documentation Improvement Specialist ensures the clinical documentation is complete and accurate and on an ongoing basis provides education and support to all members of the healthcare team regarding clinical documentation. CDIS responsibilities include concurrent review of the medical record to ensure appropriate and accurate reimbursement based on severity of illness, risk of mortality and level of services provided to patients. CDIS ensure appropriate clinical documentation by engaging the providers, nursing staff, ancillary departments, and coding staff in a collaborative manner. A SDIS demonstrates understanding, creativity, enthusiasm, and flexibility while performing in this role to meet and support program goals.

Supports, and is responsible for incorporating into job performance, the Frederick Health (FH) mission, vision, core values and customer service philosophy and adheres to the FH Compliance Program, including following all regulatory requirements and the FH Standards of Behavior.

Example of Essential Functions:

* Acts as primary preceptor for new CDIS team members, develops training schedule and program, and regularly communicates progress with departmental leadership.

* Is an expert of CDIS role and represents the CDIS team in strategic planning for the department and organization.

* Maintains knowledge of best practices and industry standards through participation in national and local associations and relays information to CDIS team.

* Coordinates CDIS schedule and distributes to departmental leadership.

* Prepares and leads weekly internal CDIS team meetings, and collaborates with departmental leadership to prepare monthly CDIS staff meetings.

* Coordinates and leads monthly CDI Peer Review meetings and communicates findings with departmental leadership.

* Collaborates with departmental leadership to develop, assess, and improve CDIS team performance goals and metrics.

* Serves as a point of contact within the CDIS team for and maintains regular communication with 3M 360 program (including updates, upgrades, concerns, questions).

* Coordinates, prepares, and co-leads other regular CDIS meetings and collaborative efforts (including CDI Physician Advisory, CDI/Coding Monthly Collaborative, CDI/Coding Reconciliation).

* Maintains detailed minutes, agendas and action items from regular CDIS meetings and collaborations.

* Provides reports from 3M 360 to help support and drive strategic initiatives within the department and organization.

* Participates in probationary and annual CDIS reviews to provide feedback to departmental leadership.

* Concurrently reviews the inpatient medical record within 24 - 48 hrs. of admission for potential areas of opportunity regarding clinical documentation of principle and secondary diagnosis and procedures in order to assign a working APR-DRG based on complete medical record documentation.

* Conducts admission and continued stay reviews within 48 hrs. of admission on all selected cases and documents findings on worksheets and tracking forms based on department standards and expectations.

* Conducts follow up reviews of documentation for responses to physician queries in a timely manner per department policy.

* Communicates with physicians and other members of the healthcare team in a collaborative and educational manner through written and verbal dialogue.

* Assumes a leadership role in ensuring documentation in the medical record accurately and completely reflects the severity of illness, and risk of mortality.

* Confers as appropriate with Performance Improvement staff to ensure the plan of care and treatment course identified for the patient is appropriate and consistent with current medical issues and best practices.

* Works closely with HIM coding staff to assure documentation of diagnosis(es) and any co-existing co-morbidities are a complete reflection of the patient's clinical status and care.

* Serves as a resource to physicians, coders and other members of the healthcare team regarding issues of appropriateness of clinical documentation and DRG assignment.

* Utilizes CDS monitoring tools to track program progress, effectiveness, and opportunities for improvement or education and shares this information with the appropriate individuals.

* Demonstrates a working knowledge of case management activities, including work processes, standards, practices and interventions.

* Consistently demonstrates collaborative and supportive written and verbal communication skills.

* Documents clearly and timely based on department standards on the CDI tracking form.

* Maintains close working relationships with coding professionals to ensure appropriate APR-DRG assignment and further review the medical record for discrepancies in assignment.

* Fosters cordial, positive, and professional interpersonal relationships with physicians, coders, peers and other members of the healthcare team.

* Refers appropriate cases to department team members for case management, discharge planning or social work services as appropriate.

* Written queries are clearly documented in the medical record.

* Serves as a liaison to the Performance Improvement Department.

* Acts as a proactive and participatory member of the Performance Improvement Department

* Ensures that quality of care concerns are reported to the appropriate staff person, Performance Improvement Department or Risk Management Department.

* Uses PC communication tools in a timely and effective manner: monitors OA messages, e-mails, and voice mails throughout the day and responds accordingly.

* Develops and implements plans for ongoing Clinical Documentation Improvement education for new staff, including physicians, coders, nursing, and other members of the healthcare team. This involves routine meetings with the coding team, the Hospitalist RNs, the MHAC team, in addition to 1:1 training with all of the healthcare team members as necessary.

* Designs and implements in collaboration with physician leadership specific tools to support physician documentation.

* Maintains knowledge of federal and state clinical documentation and coding requirements and guidelines.

* Actively engages medical and healthcare provider staff regarding clinical documentation guidelines and requirements, informing them of changes in practice and or requirements.

* Analyzes CDI data for educational opportunities, plans and coordinates education with appropriate individuals and or groups.

* Actively maintains professional knowledge of clinical documentation activities and engages in continuing education activities.

* Maintains working knowledge of utilization review practices and standards, including patient status.

* Attends a minimum of 90% of monthly CDIS staff department meetings and shares in discussions.

* Attends a minimum of 90% of department staff meetings and in-services and actively participates by presenting issues, along with proposed suggestions for resolution.

* Reads minutes from staff meetings and department in-services when not working the day of the meeting/in-service.

* Attends a minimum of 90% of coding /CDI meetings and is responsible for reading the minutes if unable to attend.

* Attends a minimum of 90% of Advisory board CDI and Physician education meetings and is responsible for reading the minutes if unable to attend.

* Reads and initials all department memos regarding updates and policy changes.

* Actively participates in department and organization wide quality improvement efforts as appropriate.

* Identifies and analyzes variances from expected outcomes and works toward a resolution.

* Possess a working knowledge of financial terms, i.e. PPO, HMO, and reimbursement practices and requirements.

* Maintains current knowledge of JCAHO guidelines, Frederick Memorial Hospital Utilization Review Plan, and DRG reimbursement with expected length of stay.

* Contributes to annual evaluation of department QA/I program.

* Develops and locates specific community resources, as appropriate.

* Maintains a 95-100% productivity based on Advisory Board recommendation of 10-12 new patient assessments and 14 re-assessments daily.

* Reviews and reports activity /progress with Physician Queries and updates the database in the PI office daily.

* Contributes to the audit and appeals process when appropriate.

* Willingly accepts additional duties and responsibilities.

* Volunteers to serve on task forces or committees and participates in special projects in the department, hospital and/or community.

* Participates in discharge planning, when needed.

Required Knowledge, Skills and Abilities:

* Knowledge of acute care regulatory requirements and healthcare revenue cycle.

* Exhibits effective interpersonal and communication skills.

* Demonstrates a high level of tact, diplomacy, and negotiation skills.

* Demonstrates positive customer service skills.

* Demonstrates analytical skills in interpreting data and trends.

* Demonstrates the ability to apply critical and creative thinking skills.

* Demonstrates the ability to prioritize assignments.

* Employs effective time management skills and techniques.

* Possess knowledge of medical terminology and practices.

Minimum Education, Training, and Experience Required:

* Registered Nurse from an accredited school of nursing with a current Maryland license, BSN required, or minimum of Bachelor's prepared health related degree.

* Two or more years of clinical documentation improvement experience.

* Three to five-years clinical experience.

Patient Contact

Must demonstrate and maintain current knowledge and skills in providing appropriate care/contact for patients in the following age groups:

_ Performance of job does not require patient contact

Physical Demands:

Sedentary - Light Work - Lifting up to 15 pounds on an infrequent basis (less than one lift every three minutes). While work is mostly done sitting, a certain amount of walking or standing is often necessary.

Ergonomic Risk Factors:

Repetition: Repeating the same motion over and over again places stress on the muscles and tendons. The severity of risk depends on how often the action is repeated, the speed of the movement, the required force and muscles involved.

Awkward Posture: Posture is the position your body is in and its effect on the muscle groups that are involved in the physical activity. Awkward postures include repeated or prolonged reaching, twisting, bending, kneeling, squatting, working overhead with your hands or arms, or holding fixed positions.

Working Conditions:

* Bloodborne Pathogens Exposure Risk: Category C - NO exposure to blood or body fluids.

Reporting Relationship:

Reports to Manager, Performance Improvement