Job Information
Finger Lakes Health Clinical Documentation Improvement Specialist in Geneva, New York
POSITION SUMMARY:
Perform a concurrent review of the medical record to ensuring provider documentation is clear, concise, complete and legible. CDIS will review inpatient medical records daily, concurrent with patient stay, to identify opportunities to clarify documentation deficiencies. The CDIS facilitates modifications to clinical documentation through concurrent (pre-bill) interaction with providers and other members of the healthcare team that accurately reflects clinical severity that is ultimately translated into coded data that supports the level of service rendered.
QUALIFICATIONS:
EDUCATION:
Minimum:
Associate's or Bachelor's degree in Nursing with 3-5 years of experience and a strong clinical background.
LICENSE:
PROFESSIONAL CERTIFICATIONS:
Minimum :
CDI certification (CCDS or CDIP) after two years of CDI experience
WORK EXPERIENCE:
Minimum:
Three -Five years of experience of acute care and a strong clinical background.
Experience in Acute Care Settings (CCU, ER, OR, ICU) CDIS must have advanced clinical expertise and knowledge of complex disease, comorbidities, severity of illness (SOI), Risk of Mortality (ROM), case mix, and the impact of procedures on the billed record.
Ability to understand coding concepts, guidelines and clinical terminology as well as anatomy and physiology, pathophysiology and pharmacology.
CDIS must have advanced clinical expertise and knowledge of complex disease, comorbidities, severity of illness (SOI), Risk of Mortality (ROM), case mix, and the impact of procedures on the billed record.
SKILLS:
Minimum:
Excellent communication interpersonal and organizational skills.
Possess and maintain excellent verbal /written communication skills which foster positive working relationships required to collaborate with providers, case managers, coders, and other members of the healthcare team.
Strong critical thinking skills; must possess the ability to read and analyze all information in a medical record.
Must have current knowledge and ability to adapt to changing federal, state, and private payer regulations in addition to quality improvement, core measures, safety, and regulated reporting programs.
Candidate should value high quality standards as evidenced by reliability, consistency, accuracy, integrity, and validity of CDI practices and process, following official coding rules and guidelines as well as regulatory reimbursement policies issued by CMS and other payers.
Ability to work independently and meet productivity requirements.
CDIS must be self-motivated, work independently, and adapt to changes in healthcare.
Salary Range: $40.61-$45.31