Clinical Dcoumentation Improvement (CDI) Liaison in Houston, TX at Parallon

Date Posted: 5/12/2018

Job Snapshot

  • Employee Type:
    Full-Time
  • Location:
    Houston, TX
  • Job Type:
    Other
  • Experience:
    At least 5 year(s)
  • Date Posted:
    5/12/2018

Job Description

GENERAL SUMMARY OF DUTIES
The Clinical Documentation Improvement Specialist (CDS) performs concurrent review of the medical record, issues concurrent physician inquiries, and interacts with the medical staff and other caregivers in an effort to assure complete and accurate documentation of the patient’s clinical picture and the treatment provided. The CDS acts as a liaison between Coding professionals and the medical staff.

 
 
DUTIES INCLUDE BUT ARE NOT LIMITED TO:
  • 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
  • Reviews medical records and identifies potential gaps in clinical documentation for specified patient types (e.g., I/P, O/P, etc.) and payer populations (e.g., Medicare, Medicaid, Blue Cross/Blue Shield, etc.) as directed on admission and throughout hospitalization
  • Queries physicians and other caregivers as necessary via approved written communication mechanisms to obtain accurate and complete documentation that supports the severity of patient illness, intensity of services and risk of mortality
  • Completes concurrent review on 85% of assigned population
  • Achieves and maintains 95% accuracy rate
  • Works closely with coding staff to assure documentation of discharge diagnoses and any co-existing comorbidities or complications to completely reflect the patient’s clinical status and care
  • Demonstrates basic knowledge of coding standards and application to ongoing evaluation of medical record documentation
  • Develops and implements plans for both formal and informal education of physician, nursing, and other clinical staff
  • Identifies strategies through data gathering and analysis of trends to establish recommendations for sustained work process changes that facilitate complete, accurate clinical documentation
  • Consistently meets established productivity targets for record review
  • Practice and adhere to the “Code of Conduct” philosophy and “Mission and Value Statement”
  • Other duties as assigned



Job Requirements

EDUCATION
Undergraduate degree in Health Information Management, Nursing or health care related field required


 

EXPERIENCE

  • Minimum 5 years recent health information management, case management/utilization/quality review and/or other related clinical experience in an acute care facility required; 3 years acute care inpatient coding experience preferred
  • Knowledge base of ICD-9-CM coding and understanding of Diagnostic Related Groups (DRGs) required

     

CERTIFICATE/LICENSE

RHIA, RHIT, CCS, RN or LPN required