Heywood Hospital Coordinator of Clinical Documentation Improvement in Gardner, Massachusetts

Job Summary

Demonstrates strong organizational skills with demonstrated leadership ability. Strong communication skills adaptable to a wide variety of interpersonal encounters with the entire healthcare team and the ability to present ideas and concepts effectively to physicians, management and employees. Demonstrates the ability to develop and maintain supportive, collaborative relationships with physicians. Demonstrates highly developed problem solving skills and self-directed, motivated behavior. Strong computer/PC skills essential.

Serves as a subject matter expert in clinical data reporting and leads the improvement of the overall quality and completeness of clinical documentation through the application of evidence-based knowledge, analysis, in-depth review, interpretation, identification of opportunities, communication and consistent follow-up and evaluation of concurrent and retrospective (as required) medical record documentation. Monitor internal key indicator metrics associated with CDI as it related to the revenue cycle and quality outcomes. Works closely with Information Technology to fully understand system upgrades and testing.

Job Requirements

Minimum Education

  • CDI specialist should ideally possess one or more of the following credentials: registered nurse, certified coding specialist, registered health information administrator, registered health information technician, certified clinical documentation specialist or certified documentation improvement practitioner

Minimum Work Experience

  • Five years experience in the clinical area, coding, process improvement or case management / utilization review in an acute care setting

Organizational Expectations

Behavioral Attributes

The following behavioral attributes are required: achievement, motivation, flexibility, concern for order, initiative, self-confidence, self control, and customer service orientation, interpersonal effectiveness, analytical and information seeking.

Functional Demands

Physical Requirements

Exerts up to 20 pounds of force occasionally, and/or up to 10 pounds of force frequently, and/or a negligible amount of force constantly to move objects. Frequently reaches (extending hands and arms in any direction), and handles (seizing, holding, grasping, turning, or working with hands).

Essential Functions

  • Facilitates and obtains appropriate provider documentation within the health record for clinical conditions and treatment required for accurate representation of severity of illness, expected risk of mortality, and complexity of care of the patient.
  • Good working knowledge of ICD-10. Knowledge of Local Medicare Review Policies. Exposure to encoder software and working knowledge of CC’s MCC’s and HCC’s.
  • Keeps current with federal legislation, periodicals and coding guidelines establishing current coding/reimbursement compliance as it relates to evaluating and assigning accurate DRG assignments.
  • Educates the medical staff and other clinicians using a variety of teaching methods including “just in time’ training to establish optimal physician documentation at admission and throughout the stay.
  • Assures timely, accurate and complete documentation of clinical information used for measuring and reporting physician and hospital outcome data through ongoing performance monitoring.
  • Assigns and monitors Case mix indices, CMI reports and tracks areas for performance improvement or non -improvement to appropriately reflect the impact of the CDI program.
  • Coordinates and supervises the HIM coding staff to assist the HIM Director with ongoing understanding/clarification of clinical documentation leading to appropriately ICD-10 codes representing patient resource consumption. I.e. reporting of wound vacs, PICC lines, pacemaker status, pass through drugs and bedside procedures etc.
  • Improves coding specificity by educating physicians, clinicians and other involved parties regarding the necessity of providing complete and clear documentation of the care provided throughout a patient’s stay. Achieved via queries, face-to-face communication and/or other educational tools useful and necessary to achieve the goal.
  • General knowledge of what constitutes a complete and accurate record—i.e., complete and thorough clinical documentation beginning with the emergency room reflective of clinical presentation of patient; reason for admission that clearly establishes and meets medical necessity criteria; need for continued stay in the hospital including response to treatments, interventions, and outcomes; complete and accurate discharge summary to include diagnoses established and conditions treated throughout the patients stay.
  • Remains current with query information to ensure accuracy of codes assigned used when there is conflicting or incomplete documentation. Information will include the AHA Coding Clinic publication, pharmacology, laboratory, disease processes, CDIS Coding References and new/emerging technologies.
  • Participates in educational programs and in-services in order to maintain and exceed excellence in clinical and coding skills. Maintains a library of information beneficial to work.
  • Keeps the CDI database updated and current. Produces a monthly summary report of cases reviewed and other reports as requested.
  • Flexible, organized, strong oral and written communication, skills and can easily build rapport with physicians & the multidisciplinary team.
  • Conducts initial and extended-stay reviews on all selected admissions and documents findings in the 3M system, denoting all key information utilized in the tracking process.
  • Familiarity the Inpatient Prospective Payment System (IPPS), including, the Comprehensive Error Rate Testing (CERT) program and familiarity of the Short Term hospital PEPPER report
  • Ability to obtain documentation relevant to denials avoidance related to the Recovery Audit program, (CERT), and other audit programs, recognizing and disseminating to physicians the synergies of clinical documentation for both the physician and the hospital.
  • Utilizes monitoring tools to track the progress of the CDI program through interpretation of DRG reports, monitoring reports and data. Shares findings in meeting with the Director of HIM, other directors and Admin staff as required.
  • Able to identify areas of need of focus through report analysis.
  • Acts as a bridge between providers and other staff to support CDI, utilization review, and claim denials management.
  • Assists in the development of query reports, response rates, TAT, and type of queries and type of responses.
  • Maintains complete confidentiality of patient information, in addition to hospital and individual physician practice pattern data.

Statement of Other Duties

This document describes the major duties and responsibilities for this job, and is not intended to be a complete list of all tasks and functions. It should be understood, therefore, that employees may be asked to perform job-related duties beyond those explicitly described.

Facility: Heywood Hospital

Department: HH. MEDICAL REC.-,6240

Regular or Temporary Position: Regular

Position Control #: 6240XXX00101

Position Hours: 40

Shift: Day

Job Title: Coordinator of Clinical Documentation Improvement

Location: Gardner, Massachusetts

Posted Date: 03/21/2018