Clinical Documentation and Data Integrity Specialist, Senior (Mount Vernon)

Company: Nuvance Health
Location: Mount Vernon
Posted on: January 7, 2021

Job Description:

Summary: The Senior Clinical Documentation and Data Integrity Specialist (CDDIS) is responsible for the overall improvement of the quality and completeness of Medical Record Documentation. Provides support in program development, implementation and sustaining a hospital wide documentation integrity program. The senior CDDIS will collaborate with Lead and CDDI Manager to serve as a resource on documentation and related coding issues for junior staff in addition to medical provider and other relevant team members. Provide ongoing education to physicians and other front line clinical staff to assure appropriate DRG assignment, documentation of severity of illness and risk of mortality. Reviews expected daily case volume both new and recurrent from daily work list and capture accurate SOI, ROM data. Provide support to ensure that clinical information and quality data utilized in profiling and reporting is complete and accurate. Review and validate POA status for Hospital Acquired Complication with providers when needed and correspond with quality team. Identify and review Patient Safety and Adverse Event, PSI complication for clinical validation using AHRQ provide inclusion exclusion criteria. Collaborate with Denial unit in chart review to validate coding and appropriate DRG assignment as well as review observation and inpatient status. This position requires full-time onsite presence.Responsibilities1. Reviews inpatient medical records for identified payer population as directed on admission and throughout hospitalization. Analyze clinical status of patient, current treatment plan and past medical history and identifies potential gaps in physician documentation. 2. Identifies issues requiring clarification or additional information in the clinical documentation and initiates communication with the appropriate physician or other care provider using the established CDI Program processes.3. Works with lead CDDI to helps educate new physicians and other care providers about how to effectively and thoroughly document in the medical record during their "on-boarding" process.4. Assists in providing feedback to medical staff regarding performance related to case mix index, severity of illness, risk of mortality, PSI, HAC and other relevant indicators identified by the CDDI program.5. Maintains an open and collaborative working relationship with the patient care team, physician champions, and care coordination, denial management, quality and HIM coding staff.6. Participates in CDI team meetings to discuss difficult cases, questions and performance improvement strategies.7. Identifies trends or potential problems and works proactively to find and implement solutions.8. Accurately identifies and reports outliers to Lead and or Manager of CDI program.Communicates and discusses documentation clarification requests with coding staff, physician champions, quality and case management unitsOther Information One of the following certification upon hiring, CDIP, CCDS or acquire within 6 months of hiringExperience working in inpatient setting for 3 years, 5 years is a plus Experience with clinical documentation integrity and reportable quality data measures (PSI, HAC)Have worked in large health system with multiple acute care hospitalsEducationWorking ConditionsEssential:* Some manual skills / motor coord & finger dexterity* Sedentary/light effort. May exert up to 10 lbs. force* Some exposure to dirt, odors, noise, human waste, etc.* Some occupational riskLocation: Danbury-24 Hospital Ave.Org Unit: 282Department: Clincial Document ImprovementWork Type: Full-TimeStandard Hours: 40.00FTE: 1.000000Work Schedule: Day 8Exempt from Overtime: Exempt: YesWestern Connecticut Health Network and its affiliates are Section 501(c)(3) tax-exempt organizations and therefore eligible employees may qualify for forgiveness of certain federal student loans under the Public Service Loan Forgiveness Program.Associated topics: biopharma, biopharmaceutical, dietician, food, food scientist, health, immunohematology, injury, patient, protein

Keywords: Nuvance Health, Mount Vernon , Clinical Documentation and Data Integrity Specialist, Senior (Mount Vernon), Healthcare , Mount Vernon, New York