Clinical Documentation Improvement Specialist - South Shore Health

Job Description Summary

Under the general supervision of the Manager of Clinical Documentation, will assist to develop, implement, and maintain the documentation accuracy initiative at the Hospital. This position is responsible for the concurrent review of the clinical documentation in the medical record and concurrent querying of medical staff caregivers to obtain accurate and complete documentation, which appropriately supports the severity of patient illness. This is a hybrid role.

Job Description

Essential Fucntions

1. Performs concurrent review process for all selected admissions to ensure documentation accurately reflects the severity of patient’s illness

a. Produce worklists from Meditech daily to review case on day 2 as well as daily throughout the patient’s stay. Patients admitted and discharged on the weekend will be reviewed in coding before the bill is dropped. Review all inpatient cases and observation or surgical day cases that has the potential to be converted to an inpatient admission

b. Identifies and records principle and secondary diagnoses, principle procedures, and assigns a working DRG on Documentation worksheet.

c. Identifies need to clarify documentation in records and initiates assertive communication with physician or other care provider by using the most appropriate communication method for that individual – physician documentation request, face to face contact, phone call, etc.

d. Inputs current DRG into Meditech for all Medicare patients daily.

e. Inputs and reconciles queries on excel datasheet daily.


2. Provide information and education as necessary to physicians and other care providers specific to DAP.

a. Present overview of program to new physicians and other care providers at orientation

b. Follow up with new physicians who document in medical records in a one to one meeting

c. Provide ongoing information/education as necessary to physicians and other care providers not responding to documentation requests

d. Assist in providing feedback to medical staff regarding performance as it relates to accuracy of opportunities to improve documentation.

e. Continual medical staff education as a proactive measure.


3. Maintains a collaborative working relationship with team and with the Health Information Management department staff.

a. Perform focused reviews, both concurrently and retrospectively, to determine areas where information and/or education may be required for the team or members of the team to improve program effectiveness

b. Perform focused reviews, both concurrently and retrospectively, to determine areas where information and/or education may be required for physicians or other care providers to improve program effectiveness

c. Share pertinent coding and DRG reference materials (e.g. coding clinics)

d. Share pertinent clinical information (e.g. new drugs/treatments)

e. Identification of improvements needed by physicians with continued documentation needs to medical staff liaison for further action


4. Reviews, evaluates, analyzes and interprets data related to documentation from internal sources and external sources on an on-going basis

a. Identifies trends or potential problems and assists in developing action plans to address.


5. Track and provide regular (monthly, other) report for mortality, queries, and case mix in support of hospital wide initiatives.

6. Participates in organizational surveys that evaluate staff perception of safety.

7. Seeks and participates in educational opportunities to improve job skills and program.

8. Demonstrates knowledge of organizational safety priorities and their department specific application, methods of reporting safety concerns and opportunities.

9. Identifies annually at least one implementable idea to improve patient, staff or environmental safety.

10. Successfully answers safety questions in annual mandatory education program.

11. Understands roles/responsibilities during hospital codes.

12. Adheres to respiratory etiquette guidelines.


Essential Functions (Cont.)

I. Technology and Learning

a. Participates in continued learning and possess a willingness and ability to learn and utilize new technology and procedures that continue to develop in their role and throughout the organization.

b. Embraces technological advances that allow us to communicate information effectively and efficiently based on role.


Non-Essential Functions

Non-essential functions are those tasks, duties and responsibilities that are not critical to the performance of the job. Following are non-essential functions of the job, along with the corresponding performance standards.

1. Other duties as required.

Excellent communication and critical thinking skills. Demonstrates leadership qualities such as the ability to motivate, teach, and facilitate individuals and groups on reaching the objectives of the program. Working knowledge of Medicare and Blue Cross inpatient reimbursement and coding structures is desired. Knowledge of care delivery documentation systems and related medical record documents desired. Knowledge of age-specific needs and the elements of disease processes and related procedures preferred. Self-motivated, innovative individual who has the ability to work in a time oriented environment. Prefer experience interacting with physicians and concurrent review with clinical records. Basic personal computer skills required.