Clinical Documentation and Data Integrity Specialist, Senior (Mount Vernon)
Company: Nuvance Health
Location: Mount Vernon
Posted on: January 7, 2021
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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
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