Clinical Documentation Improvement Specialist (Hospital)

9567
Clinical Documentation Improvement Specialist (Hospital)
Health Care
Miami

The Clinical Documentation Improvement Specialists performs on-site medical record reviews, examining and assessing all patient documentation to ensure that all information including the illness diagnosis is accurate. This is accomplished by a concurrent and retrospective review of medical records.  Responsible for the validation of diagnosis codes and the identification of missing diagnosis so that patient severity of illness is properly reflected in the medical record. Must meet compliance with Centers for Medicare & Medicaid Services’ (CMS) risk adjustment guidelines, Association of Certified Documentation Improvement Specialists (ACDIS), American Association of Professional Coders (AAPC) and the American Health Information Management Associations (AHIMA) coding and documentation guidelines. The incumbent of this position evaluates utilization and documentation of acute care services and ensures that proper medical diagnoses are being submitted for reimbursement from CMS.

ESSENTIAL DUTIES AND RESPONSIBILITIES

• Conducts an extensive analysis of patient records to evaluate documentation of principal diagnosis and all applicable secondary diagnoses.
• Obtains and promotes appropriate clinical documentation through extensive interaction with physicians, nursing staff, other patient caregivers, and coding staff to ensure that the documentation of the level of service rendered to the patient and the patient’s clinical complexity is complete and accurate.
• Links ICD-10-CM coding guidelines and medical terminology to improve accuracy of patient severity of illness (SOI), risk of mortality (ROM) and final code assignment.
• Tabulates and analyzes data on ongoing basis.
• Reviews medical records or ensure that diagnoses are reported in accordance with CMS payment guidelines.
• Maintains working relationships with physicians and other caregivers.
• Compiles data to determine areas of coding improvement, physician and staff training and to improve communication.
• Wears a complete uniform and keeps a clean and neat appearance during working hours.
• Demonstrates courtesy and politeness to patients, visitors and other employees.